About a third of South Africa’s population lives in rural areas — our Covid vaccine roll-out would therefore need to cover remote areas sufficiently to meet its target of immunising all eligible adults by the end of 2021.

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 Xhora 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 populations.

Meanwhile, provinces that are home to the country’s biggest cities, such as Gauteng, the Western Cape and KwaZulu-Natal, are lagging behind, somewhere between the 18% and 25% mark. 

So what did Limpopo and the Eastern Cape do right and how have they overcome the challenges of getting vaccines to isolated communities? We break it down.

Challenge 1: Remote areas are hard to reach 

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 difficult for their outreach team to find these villages and homes, and they often 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 of 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, 30km from Nqileni Village in the Xhora Mouth area. The nearest town, Elliotdale, is another 30km 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 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 have the money or the motivation to use the small amount of money they do have to go and get a vaccine.”

Transporting people from distant villages to far-off sites is not always the best option — it’s expensive and time-consuming. 

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 that driving 200 people to the site and back costs around R18,000 in taxi fares, which is not something that can be repeated too often.

Solution 1: Go to the people

Partnering with nonprofits to help with roll-outs in remote areas is a strategy provincial health departments have benefited from. Nonprofits that work in these 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 remote areas can consider is called the “hub-and-spoke” model, which the Eastern Cape follows.

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 by BMC Health Services Research.

The “hub” is the district hospital and 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 to have community mobile workers go out to the areas with the clinic and register people, as well as create demand,” he says. “Then community health workers go out and get people to the facility to be vaccinated.”

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

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 26,000.

They credited this partly to their plan of taking vaccinations to where the people are. For instance, they 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 to get sports enthusiasts onboard.

“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 commit to being vaccinated, they will then go on to encourage others to do the same.

Challenge 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 and 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 that took hours to reach because there had been no awareness or sensitisation campaigns in the community.

Solution 2: Go door-to-door and talk to people 

“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 scheduled vaccination days. Chaps’ workers also hand out educational pamphlets, but these have been less successful in engaging communities compared to 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 and religious leaders and ward councillors, Pienaar says.

The 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. 

Challenge 3: Mistrust of new service providers 

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

Pienaar says that 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 “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 communities,” 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 vaccines.”

Solution 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.

Challenge 4: A lot of logistics

A lot of work goes on behind the scenes to make the process of getting jabs into people’s arms as seamless as possible.

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 that everyone has the correct protective gear.

“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 pharmacists.

District pharmacies have to prepare and supply the jabs to mobile teams, who then deliver them to community sites. If the pharmacy only opens at 9am, 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 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. For instance, Wilkinson says, it’s very rare for people in villages to know what subdistrict they live in — and often their district does not even appear on the EVDS. 

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

Solution 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 9am, vehicles can only hit the road by 9.30am 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 75%. 

“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.” 

Challenge 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 later.

For this reason, the national roll-out organisers planned to use Johnson & Johnson’s 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.”

Solution 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 ensure that all but two of the 200 people over 60 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 those who hadn’t returned for dose number two. 

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 the jab.

“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 go.” DM/MC

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.