Ethiopia’s EPI is managed through a decentralised system, distributing responsibilities across different government levels. Nationally, the EPI is overseen by a desk within the Reproductive, Maternal, Neonatal, Child, Adolescent Health, and Nutrition (RMNCAH-N) Directorate of the Ministry of Health (MoH) Ethiopia. In 2023, this desk—responsible for serving a country of over 128 million people ⁶ —was staffed by only three regular professionals, with additional support from partner-seconded staff. It also receives guidance from bodies, including the National Immunisation Technical Advisory Group (E-NITAG), the Immunisation Task Force (ITF), the Interagency Coordinating Committee (ICC), and various Technical Working Groups (TWGs). The EPI Desk also collaborates with the Ethiopian Public Health Institute (EPHI) for research and programme monitoring, the Ethiopian Pharmaceutical Supply Service (EPSS) for vaccine supply and cold chain management, and the Ethiopian Food and Drug Authority (EFDA) for emergency services and public awareness.

Regionally, EPI implementation falls under the purview of health bureaus’ RMNCAH-N Directorates, typically with only one dedicated EPI expert in almost all regions. At the zonal level, child healthcare units, via designated EPI focal persons, manage immunisation activities. Woreda-level EPI are overseen by focal persons within maternal and child healthcare units. Primary hospitals and health centers rely on one or two focal persons, while health extension workers at health posts deliver immunisations alongside other duties.

Although immunisation services in Ethiopia have expanded to thirteen antigens beyond the original six, the structure of the EPI, established over four decades ago, has remained largely unchanged. This outdated system poses significant challenges to key programmatic areas, including supervision and performance monitoring, service delivery, vaccine and immunisation supply chain management, immunisation quality and safety, vaccine-preventable disease surveillance, demand generation and communication strategies, and the monitoring and evaluation of programme outcomes. Consequently, Ethiopia’s EPI effectiveness and efficiency lag behind other sub-Saharan African nations with more robust structures. These organisational structural weaknesses also contribute to decreased data utilisation, ineffective planning, and inadequate monitoring and evaluation at all administrative levels, deviating from the World Health Organisation (WHO)’s functional units’ recommendations. ^{7, 8} The introduction of new antigens, dose shift and increasing population will further strain this already overburdened system.

The findings of the current evaluation study found that Ethiopia’s national EPI unit, structured as a single desk rather than a department with units, severely limits its number of professional staff employed. This critical staffing shortage is currently filled by partner-appointed staff, a solution dependent on funding and therefore unpredictable. One major consequence of the outdated structure of Ethiopia’s EPI is the inadequate allocation of human resources. Currently, only three professionals manage the National Immunisation Programme (NIP) for a population exceeding 128 million—an evident disparity when compared to Kenya, which has 20 professionals for 56 million people, ⁹ and Rwanda, with 12 professionals for 14 million. ¹⁰ This limited staffing undermines critical functions such as supervision, performance monitoring, service delivery, vaccine supply chain management, and demand generation. These structural constraints underscore the urgent need for reform to improve the efficiency and effectiveness of immunisation services. ¹⁰ Revising the organisational structure of Ethiopia’s NIP is therefore essential to meet the growing demands of the programme.

Similarly, the study ⁵ found that the immunisation programme’s inadequate organisational structure at lower levels (regional, zonal, woreda and facility), with immunisation subsumed within other units and managed by single focal persons, has created critical workforce shortages, a lack of ownership and accountability, and obscure roles and responsibilities.

Despite the expansion of the immunisation programme’s scope and objectives at the regional, zonal, and woreda levels, its organisational structure has not evolved accordingly. At the regional level, immunisation activities are housed within the Maternal and Child Health (MCH) unit and managed by a single focal person. At the zonal level, there is no dedicated immunisation lead; instead, one individual is responsible for child health, nutrition, and immunisation collectively. Similarly, at the woreda level, a single focal person oversees the entire MCH portfolio, including immunisation. This lack of dedicated EPI personnel at each level leads to operational strain, role ambiguity, and excessive workload. As immunisation responsibilities are added to the already broad mandates of general health professionals, program oversight and accountability are weakened, limiting the programme’s effectiveness.

The structural inadequacy continues at the health facility level (primary hospitals, health centres, and health posts). EPI focal persons are often burdened with additional responsibilities beyond immunization, such as working in outpatient departments. This diffusion of duties compromises the dedicated attention required for effective immunization services. The challenge of workload and inadequacy of the structure to accommodate additional work force for specific immunization service is even prominently seen at health post level. Moreover, community structures, such as the health development army, are reported to be loosely functioning, failing to adequately support HEWs in community engagement. This turnover and frequent rotation create inconsistent staffing and variable assignment timeframes for immunisation focal persons, negatively impacting service delivery.

To address the organisational structural challenges of the EPI in Ethiopia, the following areas of improvement have been identified: •

The organisational structure at all levels needs to be revised to be more responsive to the demands of immunisation services by all stakeholders.

Based on the identified areas of improvement, the following policy options have been recommended for consideration in Ethiopia:

This study received ethical approval from the Institutional Review Board (IRB) of the College of Medicine and Health Sciences, Hawassa University, Ethiopia. The IRB reviewed and approved the research protocol under Ref. No: IRB/288/15 on 07 April 2023. The approval was valid from 07 April 2023 to 06 April 2024. Ethical clearance was granted after ensuring that the research adhered to the principles stated in the Declaration of Helsinki and that the objectives and methods were ethically sound.

The data presented in this brief were collected through in-depth interviews and focus group discussions with adults aged 18 years and older. Each participant received comprehensive information about the purpose of the study, data collection procedures, confidentiality, and their right to withdraw at any point without penalty. Given the minimal risk involved, the IRB explicitly approved the use of verbal informed consent in lieu of written consent. Verbal informed consent was obtained from all participants prior to data collection.

The IRB is affiliated with Hawassa University, and the study was conducted in collaboration with the Consortium of CBPM Universities in Ethiopia (Addis Ababa, Haramaya, Hawassa, Jimma, and Gondar Universities).