People Driving Vaccines in Communities.

In Ntchisi, a central district of Malawi, just one and half hour drive from the capital Lilongwe, Joshua Mwenda is busy at work. He is looking at what seems to be a log book.

“I am looking at these reports from my outreach area, which is almost all this district,” said Mwenda as he looked over the queue of patients — mostly children strapped on the backs of their mothers — waiting for diagnosis and treatment from the medical staff. “I think this district is doing pretty well when it comes to vaccination and other treatments.”

Mwenda’s seemingly bragging attitude is not without substance. Back in the capital, Doreen Ali, National Director of Community Health Services pointed at Ntchisi as one of the districts that has done ‘extremely well’ during the COVID-19 vaccination campaign. The campaign started in 2021 and is still underway.

People like Mwenda coordinate community health workers also called Health Surveillance Assistants (HSAs), sort of foot soldiers who travel door-to-door to deliver the vaccines and other primary health services.

HSAs are grassroots health care providers in Malawi. They spearhead provision of an essential package of community health services. Malawi decided to increase the number of HSAs to cater for 1000 population per HSA.

Their duties include detection and reporting of disease outbreaks, working directly with village and community leaders to identify and form community support groups including health committees, volunteers, and other local service providers. These community ties were crucial at the onset of COVID-19 vaccination. 

“We engaged community structures through local leaders and these consist of influential leaders and traditional authorities. When our workers went in the field, the ground had already been prepared. But our workers are also hardworking and we delivered well,” he said.

In addition, local leaders had bylaws which encouraged people to get vaccinated.

Mwenda prefers to work from Malomo health centre, as opposed to the more urbanised Ntchisi administrative centre — or Boma — as it’s known. This is partly to stay close to the communities and easily coordinate the workers who are based in the communities.

“This hospital has got a catchment area and every area has HSA and their main duty is to provide primary health care. The patients that you’re seeing here have been referred from village clinics,” he said adding that they also have community outreach services.

To arrive at the Malomo health centre, one has to trail through a stretch of rugged and dusty road intercepted by tarmac road (the road is now being tarred) from the district hospital. The distance almost covers 32 kilometres. The hundreds of thousands of people in the village between the two facilities would have to make the long trip for treatment. The presence of community health workers could not be more essential.

Long distances to the hospitals is one of the biggest challenges in the country. In some instances patients, including children and pregnant mothers, have to be ferried over dozens of kilometres. To lessen the burden on communities — and make the COVID vaccine drive more attractive — the ministry of health integrated the vaccination with other services.

During outreach clinics, teams travel with doctors who provide other services like testing and treating malaria, and family planning. The department of health services at the Blantyre District Council — the commercial capital of the country was even more innovative.

In May 2021 the country had to destroy thousands of COVID vaccine doses that were close to expiration. The jabs could not be administered because of logistic challenges, and demand was low – partly due to hesitancy fuelled by misconceptions.  Authorities had to take a proactive approach to avoid further losses.

The government sent mobile vans to townships and rural areas. The trucks blasted popular songs through loudspeakers as health workers encourage people to take the shots on the public address systems. With them were doses of the vaccine and those interested were getting it right away.

Chrissy Banda, Health Promotional and Public Relations Officer for Blantyre District Council said at the time the initiative was so effective they should have implemented it the very day they started the vaccination campaign.

“We’ve reached people through churches, shopping malls and markets,” she had said while vaccinating people at a shopping mall. But this is not only a van, we also use chiefs to mobilise people and we give the shots right away in the communities.”

They carried vaccines to markets and shopping malls and calling on people to get the shot. Within weeks, all the doses had gone into arms.

Thus far the country of with approximately 17 million people, has administered a total of 8,306,224 vaccine doses.

Shots of COVID-19 vaccines are still being administered in hospitals alongside routine vaccinations. For Mphatso Mtanthiko, COVID-19 vaccinator based at Kasalika health centre in the central district of Kasungu, the perception of the people towards the vaccine changed with time.

While at first people especially women thought the vaccine would  either affect their fertility or that they will lose their pregnancy, people are now coming in good numbers.

Part of her job involves going to communities in the most  hard to reach areas. On average, she reaches 10 people a day mostly those looking for booster shots.

Susan Banda,42, from Chikonje Village in the district said getting a booster shot was good  for her confidence as memories of sick people and the dead in her community are still fresh.

“People were saying many things about the vaccine but we were called for a meeting by chiefs where community health workers briefed us on the vaccine. I got the shot a few days later and proceeded to water my vegetables without any pain,” said the mother of three while also receiving a family planning shot.

Dickson Mbewe, Senior HSA in the district notes that people had a lot of questions especially about how the vaccine could be developed so quickly. To others, their religion convinced them that it was demonic.

“The fact that we, the health workers were first to receive the vaccine and how deaths and sicknesses rose made the people to start accept the vaccine because they could differentiate those who had received and not,” he said adding that communities should be educated in times like these especially though the leaders.

Back in Kasungu, senior HSA Mwenda recalls how his team had to get creative when delivering messages around COVID-19 vaccines.

 “We told the people that if our goal as medics is to kill people then we would have killed them already because we could give them shots without their knowledge when they come to hospital with illnesses. But look, we’re even getting it ourselves including government officials. That really changed the perception of the people in one of the communities.”

This reporting was supported by the International Women’s Media Foundation’s (http://iwmf.org/ ) Global Health Reporting Initiative: Vaccines and Immunization in Africa.