SA’s Covid vaccine drive – 5 problems and solutions from rural South Africa

  • The Eastern Cape and Limpopo are tied for first place in South Africa’s
    vaccination race while provinces that house the country’s big cities such as
    Gauteng lag behind.
  • Organisations are spending thousands to taxi people in rural areas to
    vaccine sites for their double dose Pfizer vaccines in the absence of Johnson
    & Johnson’s single dose jabs.
  • Far more people could be vaccinated daily by mobile vaccine sites if
    district pharmacies were open earlier during the week and if they were open on
    weekends, say those working on the ground in rural areas.

About a third of South Africa’s residents live
in rural areas – our Covid vaccine roll-out would
therefore need to cover such areas sufficiently to meet its target to immunise
all eligible adults by the end of 2021.

Remote villages can be hard to reach, but some
rural areas have, however, excelled.

In the Eastern Cape, the Bulungula Incubator
and the provincial health department have vaccinated 95% of people over the age
of 60 with their first dose of Pfizer in the hard-to-reach villages around the
Xhora River Mouth on the Wild Coast, the organisation’s data shows.

Counterintuitively, the Eastern Cape is tied
with Limpopo for first place in South Africa’s immunisation race – both have fully immunised more than 26% of their population.

Meanwhile, provinces which house the country’s
biggest cities such as Gauteng, the Western Cape and KwaZulu-Natal lag between
the 18% and 25% mark.

So what did Limpopo and the Eastern Cape do
right and how have they overcome the challenges of taking vaccines into
hard-to-reach communities? We break it down.

1: Remote areas are hard to reach with vaccines

Some areas are just “completely off the map”,
says Jacqueline Pienaar, the executive director of the Centre for HIV/Aids
Prevention Studies, Chaps.

Chaps has been helping the health department
to reach such communities in the national vaccine roll-out. It is often
difficult for their outreach team to find such villages or homes and often they
have to rely on people from that area to direct them.

In the Eastern Cape, the Bulungula Incubator works with the provincial health department to establish
community outreach sites in the Mbhashe
district that includes the towns Dutywa, Willowvale and Elliotdale.

Lynne Wilkinson, acting director of the
Incubator, says for a long time the nearest vaccination site for the area was
Madwaleni hospital, which is about 30 kilometres away from Nqileni Village in
the Xhora Mouth area. The nearest town, Elliotdale is another 30 kilometres
from the hospital.

“People from Xhora Mouth villages have to
cross a river and catch three different taxis to get to Madwaleni Hospital,”
she says.

“That’s a good full day’s journey [on the
area’s challenging roads] and it costs a lot of money to get all the way to the
hospital for a vaccination,” Wilkinson says. “So it’s unlikely that people
will either have the money or have the motivation to use the small amount of
money that they do have to go and get a vaccine.”

Transporting people from such communities to
far-away sites is not always the best option, because it’s expensive and

In June, the Bulungula Incubator arranged
transport for community members over the age of 60 in Mbhashe
district in the Eastern Cape to get their jab, but it came at a high
cost. Wilkinson says driving around 200 people to the site and back costs
around R18 000 in taxi fares, which is not something that can easily be
accomplished again.

1: Go to the people, don’t let them come to you

Partnering with nonprofits to help with
roll-outs in remote areas, is a strategy provincial health departments have
benefitted from. Nonprofits that work in such areas know the people, roads and
challenges well.

Chaps helps districts with rural roll-outs in
five provinces including Gauteng, Western Cape, Eastern Cape, North West and
the Free State.

The organisation sets up fixed vaccination
sites that run on weekdays in some districts and one-day-only mobile sites in
the more hard-to-reach areas.

But Chaps and the provincial health
departments they work with always first do a scouting visit before they show up
with a team to set up vaccination sites. Such trips have two goals: to prepare the communities for vaccination
day and to gauge how long it takes to travel there.

Community health workers (CHWs), for instance,
go door-to-door in communities to talk to people about how the vaccines work
and what side-effects they can expect.

Another option more remote areas can adopt is
called the “hub-and-spoke” model, which the Eastern Cape

This is when a more established healthcare
facility provides a sort of “lifeline” to nearby rural hospitals in order to
make sure remote areas have continuous access to health services, according to
a 2017 paper in BMC Health
Services Research.

The “hub” is the district hospital and then
satellite clinics function as the “spokes”, explains Russell Rensburg, director
of the Rural Health Advocacy Project.

“When the vaccine roll-out opened up, what
they [the Eastern Cape] did was had community mobile workers go out to the
areas with the clinic and register people as well create demand,” he says.
“Then community health workers will go out and get people to the facility to be

Rensburg says this direct outreach works
exceptionally well to reach remote communities, although it should also be
accompanied by building infrastructure in rural healthcare facilities.

In an August presentation, the Eastern Cape
health department said that by the end of that month, they were doing an
average of almost 38 000 vaccinations per day up from around 26 000
daily vaccinations at the start of August.

They credited this partly to their plan of
taking vaccinations to where people are. For instance, their vaccine drive
targeted taxi ranks and SASSA pay points in addition to creating pop-up sites.

Most recently, the health department embarked
on a campaign at taverns in Mthatha aimed at increasing vaccine uptake among
men – who so far only account for 38% of those immunised in the province.
Aside from taverns, the department is also targeting sporting events
to try and get sport enthusiasts onboard with vaccination.

“We have included taverns in our
vaccination campaign because we want to go where men socialise and spend their
free time after work and on weekends,” said health MEC Nomakhosazana Meth.

The Mthatha tavern campaign aimed to dispel
myths and counter concerns men may have about getting the jab – such as that it
causes impotence (it doesn’t) and can kill you after two years (it can’t).

The idea is that once men come on board with
the vaccine roll-out they can then go on to encourage others to do the same.

2: People don’t go to sites they don’t know about

Although creating more sites is a great start,
it’s not enough – increasing the number of people getting vaccinated takes more
than that.

First, you need to do something to get people
to the new sites. To do that, they need to be aware of the sites, when they’re
open and someone needs to explain to them how the vaccines work.

Pienaar says her team has seen how only a
handful of people turn up at a site which took hours to reach because there
weren’t awareness and sensitisation campaigns in the community.

2: Go door-to-door and talk to people – before you start vaccinating

“Community sensitisation is paramount,”
Pienaar says. People need to be properly primed before the day of vaccination
to get sufficient uptake.

“The key,” she says, “is to give people enough
time to think through the information they’ve been given about the vaccines”.

About a week before a rural site opens, Chaps
community health workers go door-to-door, telling people about the upcoming
vaccination days. Chaps’ workers also hand out educational pamphlets, but these
have been less successful in engaging communities than face-to-face
conversations, Pienaar says.

In addition, teams drive around communities in
branded vehicles and share educational messages about vaccines over loudspeakers.

In the rural Eastern Cape, the Bulungula
Incubator has created “storyboards” to help explain the vaccination process.
Stories are told by characters that look, dress and speak like the people in
the Xhora Mouth communities, where the organisation works. The Incubator’s CHWs
helped curate the vaccination messages to suit those communities.

Preparing communities for vax day is easier
when CHWs’ campaigns are bolstered by other trusted community members including
traditional leaders, religious leaders and ward councillors, Pienaar says.

The Bulungula Incubator works hand-in-hand
with traditional leaders to explain to people how sites will work and to
announce vaccination days at community meetings, Wilkinson says.

3: Mistrust of new service providers

If people don’t trust healthcare providers,
they’re unlikely to use the services they offer.

Pienaar says often when their mobile units
arrive in communities, people will stand outside their houses and watch what
the team is doing. People will sometimes ask questions such as “what vaccine is
being used” and “what are the potential side-effects”, but, she says,
“primarily, they are just sitting around and observing”.

“There’s a big issue of trust within the
community,” Pienaar explains. “Even with sensitisation, that doesn’t give them
comfort. They want to actually see people going through the vaccination
programme – and they want to be introduced to the people who hand out the

3: Use community leaders to introduce vaccination teams

“If communities are hesitant to get their
shot, they’re not going to be convinced by people they don’t know – especially
if they have not been prepped beforehand,” says Pienaar.

That’s why Chaps work with the most trusted
community members – community leaders and ward councillors – to introduce
vaccination teams and to also set the example of getting vaccinated.

“People are more comfortable seeing people
they know, like a neighbour or community leader, get the jab and this, in turn,
builds their confidence in going to get vaccinated themselves,” she says. “It’s
really important that community members are assured that the vaccine is coming
from a legitimate source.”

In cases where people have not been alerted to
the roll-out date, Chaps uses ward councillors to reassure the community that
their teams are trustworthy.

“The ward councillors are so important to get
people to trust us. It also helps to be professionally branded and to have
uniforms,” Pienaar says.

4: There’s a lotta logistics

There’s a lot of work that goes on behind the
scenes to make the process of getting jabs into people’s arms as seamless as

The first thing is making sure you have the
right equipment, Pienaar says this ranges from securing the right vehicle that
can reach the more remote communities to ensuring everyone has the correct
protective gear needed.

“It’s a continuous supply chain that needs to
continuously feed the operational teams,” says Pienaar. “It needs to be
seamless because any delay inevitably impacts on the community’s trust of the
team coming through.”

Securing the doses themselves can be
challenging, as this depends on the operational hours of the district

District pharmacies have to prepare and supply
the jabs to mobile teams who take them to community sites. If the pharmacy only
opens at 9 am, then it delays how early the vaccination team can get to the
community as they have to wait for the vials to be prepared and then continue
travelling to wherever they have been assigned for the day – and fewer
vaccination hours means fewer people get vaccinated.

Once mobile teams get to sites, the paperwork
involved in getting people registered for vaccination takes up a considerable
amount of time.

Aside from the registration process being
electronic, the government’s electronic vaccination system’s (EVDS) questions
are more difficult to answer for people living in rural areas than for those
based in cities. Wilkinson says it’s, for instance, very rare for people in
villages to know what subdistrict they live in – and often their district does
not appear on the EVDS.

“It’s a huge amount of admin work,” the
Bulungula Incubator’s Wilkinson says. “The department of health normally sends
me a team of three to four people which I have to complement with a team of
around 12 people to be able to actually run the vaccinations.”

4: Extend pharmacies’ opening hours and pre-register people

When vaccinators show up in rural communities
late in the day, people become disgruntled, and they lose trust in the
programme, undoing the work of CHWs during community sensitisation.

That is why Pienaar says district pharmacies
need to open earlier and also need to operate over weekends (this hasn’t yet
happened). “If they only open at 9 am, vehicles can only hit the road by 9:30
am at the earliest,” Pienaar says, “and it’s often at least an hour’s drive
into communities”.

She says weekend vaccination drives in rural
areas would see a higher uptake if more prepared jabs were available – but for
that, pharmacies need to be open on Saturdays and Sundays.

Wilkinson believes the paperwork involved in
registering people on the EVDS and filling out consent forms could be cut by

“We could be vaccinating way more people than
we are at the moment because we’re constrained by the amount of paperwork and
electronic questions that have to be completed for each person.

Wilkinson’s solution to this is to create an
EVDS registration support system. “Ideally, you want to set up a system where
people can submit their names and [a community organisation or CHW] can do the
pre-registration for them.”

5: Getting people to return for their second Pfizer dose

Rural populations are largely migrant, which
means someone could be there one day but not the next. This makes it hard to
ensure that everyone who got a first Pfizer dose gets a second jab 42 days

For this reason, the national roll-out
organisers planned to use Johnson & Johnson’s (J&J) jab, which only
requires one dose, in rural areas.

But because J&J has, so far, supplied
South Africa with far fewer doses than planned, Pienaar says rural areas have
often had no choice but to use Pfizer shots.

“When we arrive people might not be there for
day 42 and then where are they going to go for their second jab?” Pienaar asks.
“They will have to arrange transport to go to a local clinic and there is no
guarantee that the clinic will have Pfizer to give them.”

5: Find more J&J jabs, create a roll-call system and build partnerships

In the deep rural Eastern Cape, the Bulungula
Incubator managed to make sure all but two of the 200 people over 60 years old
in the Xhora Mouth villages got their second Pfizer jab.

The nonprofit kept records with contact
details of everybody who was transported to vaccination sites for a first shot,
so that they could keep track of the people who hadn’t returned for dose number

Says Wilkinson: “We go and find them, we fetch
them with a car and bring them for their second vaccination.”

But behind this success was more than just a
roll-call system. The Incubator did not have the means to raise the R18 000 it
would cost to taxi those 200 elderly people to vaccine sites for round two of

“It was only possible because we partnered
with the provincial health department,” Wilkinson says, “because they helped us
with providing transport.”

Wilkinson concludes: “[Double-dose vaccines]
are really not feasible [for the rural areas], it’s been a monumental effort.

“Focusing on a one-dose regimen is the way to

story was produced by the
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