'Vaccinate My Village' Strategy in Malawi: An Effort to Boost COVID-19 Vaccination

"The use of HSAs [Health Surveillance Assistants] to conduct community-based COVID-19 vaccinations in Malawi was a game changer as it increased vaccine availability, accessibility, and acceptability at the community level."

The government of Malawi launched the COVID-19 vaccination programme on March 11 2021 with vaccine doses it received from the COVID-19 Vaccine Global Access (COVAX) Facility. To increase coverage of COVID-19 vaccine uptake, the Ministry of Health launched a 'COVID-19 express strategy' that hinged on the use of community mobilisation and mobile vans to reach out to communities with the COVID-19 vaccine. Despite such efforts, the national proportion of people vaccinated for COVID-19 among all the 29 health districts continued to be low as of March 31 2022: 4.7% - with Mangochi district at 0.7% (vs. the district's annual performance of other vaccinations under the Expanded Programme on Immunization (EPI) programme, which was one of the best-performing districts in the country at 91%). Therefore, to boost COVID-19 uptake, the researchers employed a 'vaccinate my village' (VMV) strategy adapted from existing health campaigns. This study assessed the impact of the VMV strategy on COVID-19 vaccine uptake in Mangochi district.

The VMV strategy was based on the idea that community-based delivery of the COVID-19 vaccine using health surveillance assistants (HSAs) would be easily accessible to communities, since HSAs already work in communities and enjoy community trust in health matters. In addition, using HSAs to provide COVID-19 messages on vaccine efficacy and safety might be more effective in counteracting negative community perceptions and fears.

Specifically, in the VMV strategy, door-to-door COVID-19 vaccination was done by HSAs as opposed to doctors/nurses only. The strategy was carried out through 3 steps:

1. Identification and training: The head of health services in their respective district conducted a one-day orientation of the strategy to the environmental health officers (EHO), who in turn drove a series of orientations for HSAs in their respective supervision areas.
2. Risk communication and community engagement (RCCE): After the training, EHOs and HSAs conducted community engagement meetings at the village levels of their respective catchment areas, with the participation of all community residents aged 12 and above. These meetings were designed to: (i) assess community members' knowledge of COVID-19 vaccines, (ii) increase the level of knowledge about COVID-19 vaccine services and their importance among community members, (iii) clear up misconceptions on COVID-19 vaccines, (iv) make community members aware of the potential consequences of not having a COVID-19 vaccine, and (v) mobilise communities toward uptake of COVID-19 vaccines. Concurrent with these meetings, radio panel discussions anchored by traditional leaders and health workers and COVID-19 promotional jingles were aired on the local community radio stations.
3. Implementation: Before the actual vaccination campaign, all the HSAs conducted door-to-door mobilisation in all the district villages to make prior bookings to get the COVID-19 vaccines. The district health office ensured the availability of COVID-19 logistics and supplies, including vaccines, to all the health facilities so that they were readily available to all HSAs. During the implementation, HSAs used outreach clinics and door-to-door sessions to reach people in their catchment areas to provide COVID-19 vaccines at people's homes. Concurrently, supervision was conducted by senior HSAs and EHOs. Motivation in the form of lunch allowances was given to a team of HSAs upon accomplishing the task.

The VMV strategy was implemented in all catchment areas of health facilities (rural as well as urban areas) in the country from April to September 2022.

A cross-sectional review of the data on COVID-19 vaccination obtained from the Ministry of Health, Malawi, indicated that, from March 2021 - September 2022, 4091,551 COVID-19 vaccine doses were administered, of which 2,253,546 were administered over just 6 months as a part of VMV as compared to 1,838,005 doses administered over 13 months as a part of other strategies. The proportion of Malawi's population receiving at least one dose of the COVID-19 vaccine increased substantially from 4.66 to 15.4 with the implementation of the VMV strategy (p = 0.0001). District-wise coverage of the COVID-19 vaccine also increased significantly after its implementation (p = 0.0001).

The researchers explain that vaccination in community-based settings near a place of their dwellings, like a place of worship, school, community-based organisations, and door-to-door efforts (like the VMV strategy) can be particularly helpful for economically disadvantaged populations and those residing in hard-to-reach areas. Moreover, with no public transport and a poor road network, people in Malawi must spend around US$4-6 to reach health facilities, which could be one of the primary reasons for low vaccine uptake despite being provided free of cost. VMV has overcome this issue by making the COVID-19 vaccine accessible to this underprivileged population.

In addition: "The strong partnership and trust between HSAs and their communities were essential for convincing community leaders and people to accept the messages and vaccinations related to COVID-19....The availability of incentives assisted in making the HSAs available to provide the services and have creative ways of mobilizing more people in their communities to take the COVID-19 vaccinations (like in the VMV strategy). However, sustainability measures need to be considered since these monetary incentives were mostly donated by partners."

In conclusion: "VMV's strategy ensured the delivery of the vaccine to all parts of the country, including hard-to-reach areas, through outreach clinics and door-to-door sessions by HSAs. This study established the impact of door-to-door vaccination and community-based health workers' involvement in COVID-19 vaccine uptake."