Access to Rabies Post-Exposure Prophylaxis in Tanzania: A mixed-methods and theoretically-informed study to inform policy and practise.

Introduction: Rabies remains a preventable yet fatal disease that continues to claim lives in low- and middle-income countries due to barriers in accessing post-exposure prophylaxis (PEP). With Gavi, the Vaccine Alliance, now supporting PEP provision in rabies-endemic countries, understanding access barriers is critical. Methods: We used mixed-methods to synthesise quantitative data on bite patients (>10,000) captured through an Integrated Bite Case Management platform across four regions of Tanzania, with qualitative data from hotline calls and peer-support chat established among health and veterinary workers (>3000) from 2018 to 2024. We applied an expanded healthcare access framework comprising six dimensions: availability, accessibility, affordability, accommodation, acceptability, and appropriateness to guide our analyses and assess barriers and facilitators to PEP delivery and uptake. Results: We identified interconnected barriers to PEP access including recurrent vaccine stockouts (up to 9.2% regionally); long travel distances that were greater for rural patients (34 vs 13 km for urban on average) who represented the majority at risk; and unaffordable direct and indirect costs leading bite victims to either not start or abandon PEP, incur risky delays or default to traditional remedies. Incorrect bite patient management, including misuse of biologicals sold at unregulated private pharmacies led to preventable deaths, while insufficient vaccination supplies and inadequate service hours, increased risks and costs to patients. Despite these gaps, peer-support mechanisms improved patient management and real-time problem-solving. Conclusions: PEP delivery in Tanzania is undermined by systemic barriers across all access dimensions. Addressing these requires decentralizing vaccine delivery to prioritized accessible facilities, ensuring reliable stock and supplies for intradermal administration, reducing patient costs, strengthening health worker capacity through training and support, and regulating private providers. Lessons from Tanzania highlight the need for context-sensitive, equity-focused strategies to maximize the impact of Gavi's investment and accelerate progress toward Zero by 30.