How to vaccinate the most remote villages in South Africa
Supported by the WHO Foundation. VICE World News retains complete editorial autonomy.
GQEBERHA, South Africa – The secluded seaside village of Nqileni is nestled between lush green hills and the brilliant blue of the Indian Ocean in the Eastern Cape Province of South Africa. It’s almost a four hour drive from the nearest major city on rough roads.
Many older people here say they have never seen an ambulance. Access to emergency care is so poor in Nqileni and neighboring rural communities that it was the subject of a nationwide investigation in 2015.
Meanwhile, to reach the nearest hospital, residents of Nqileni have to cross the hills on foot before reaching the wide Xhora River. There they pay a fee to row across, often in rickety wooden boats. Once on the other side it is another hike to the asphalt road where people have to pay again to get on local taxis to reach Madwaleni Hospital.
In June, when vaccines became available here for the elderly in the region, this is precisely where Nqileni’s COVID-19 vaccines were located – across the hills, across the river, on the road and to the hospital.
In surveys, around 7 in 10 adults in South Africa say they would take a COVID-19 vaccine. Yet, by mid-December, only about 45% actually had it. It’s hard to say how much of the gap is due to reluctance and how much is logistical, David Harrison, CEO of philanthropic foundation DG Murray Trust, said in September. Harrison is leading a national team working to increase immunization rates.
In a country where almost half of all people are unemployed, even the cost of a R 20 (around Â£ 2) taxi ride to and from a vaccination site might be enough to deter many people from getting a free vaccine – and this price in rural areas is often steeper.
“The tyranny of distance” is how the chief director of the Western Cape health department, Gio Perez, has described how the great distances between sparsely populated rural communities and health facilities make health care more accessible. difficult to access and more expensive to provide. Historically, areas like these have also been underfunded in healthcare budgets and workers.
Yet some rural areas in South Africa have better COVID-19 vaccine coverage than many cities.
âWhat has been surprising from the start is how well the absorption has been in rural areas, especially among the elderly in rural areas compared to younger urban populations where one would expect. easier access to vaccinations, “said the deputy director of the South African Department of Health. General Nicholas Crisp told VICE World News.
Publicly available COVID-19 vaccination statistics do not differentiate between urban and rural areas. From September, the the 22 districts of the country with the lowest vaccination coverage were a mix of densely populated urban centers and rural communities – many of which had historically poorly performing health systems. Yet 15 districts with some of the largest numbers of rural areas have delivered, on average, around 553,000 doses each since the start of deployment in May, putting them on par with some small towns on the outskirts of Gauteng but only an hour from downtown Johannesburg.
To do this, South Africa is using nongovernmental organizations to expand the capacity of hospitals and rural clinics to deliver vaccinations deep into remote communities. But experts warn there could be an unexpected price to pay.
About a decade ago, health worker Lynne Wilkinson helped pioneer HIV-positive patient collectives in Khayelitsha, one of Cape Town’s many townships – often cramped and underdeveloped areas to which South Africans blacks, mestizos and Indians were forcibly evicted during apartheid.
Today, these patient groups are helping to streamline the way some people collect their medications, whether it’s in a clinic, community room, or even a neighbor’s house.
Changing the way you deliver health care isn’t rocket science, says Wilkinson: Communities need to be involved in thinking, mobilizing and delivering health care.
âThe most important thing is to bring health care as close to people’s homes as possible,â explains Wilkinson. âEspecially in rural areas where transport is expensive, the opportunity cost of leaving home, looking after children, going without agricultureâ¦ is high. You cannot afford to go to the hospital all day to get the vaccine.
She continues, âYou need to make it easy for people to access the service you provide without huge personal costs. ”
In June, Wilkinson was the acting director of Nqileni’s health and education nonprofit, the Bulungula Incubator, when COVID-19 vaccines became available here several weeks after vaccinations began in the big cities. The incubator serves around 5,000 people in Nqileni and three other villages.
âWe knew we needed to receive the vaccines provided in the villages,â Wilkinson recalls. âBut the health service was still very reluctant in June to provide vaccines in places other than clinics. “
For example, the Bulungula incubator raised funds to rent vans to transport 200 elderly people from the region to and from the hospital for a four-day vaccination.
It cost the non-profit organization more than R15,000 (around Â£ 710). The project could not afford to continue transporting people by bus for vaccinations, but it had proven to local health authorities that it could manage a vaccination campaign. The health department therefore let the incubator expand its services, organizing vaccination campaigns in schools and in the homes of local leaders. In October, a new village mini-clinic became a health department accredited vaccination site in the village, offering vaccines on Wednesdays. The incubator also organized vaccination campaigns in schools and even in the home of a traditional chief.
In the end, the Bulungula incubator was able to immunize around 1,500 of the nearly 5,000 people it serves.
âHaving a well-functioning public hospital and clinic system with good outreach teams certainly helps in a rural vaccination campaign, but I don’t think you need it,â Wilkinson told VICE World News. âYou need to leverage partnerships with community organizations, traditional leaders and anyone who is already working on the ground. “
She continues: âOur health workers already had respect for the community because they come from the community.
But nearly 1,000 kilometers north, near South Africa’s dry and dusty platinum mining belt, Jacqueline Pienaar’s teams have not been so lucky.
Pienaar is the global health specialist at the non-profit Aurum Institute. She spent the outbreak in South Africa deploying the institute’s teams to rural areas of the Eastern Cape, KwaZulu-Natal and Northwestern provinces to support vaccination against COVID-19 and, early on, screening.
But because the Pienaar teams travel, it means the communities don’t know them.
âWhat we learned early on is that people will kick us out of communities if they don’t trust what we’re doing,â she says. In KwaZulu-Natal, some of the Aurum COVID-19 screening staff have even received death threats.
Today, the organization spends up to two weeks having repeated meetings with traditional leaders and local elected officials to build trust and access communities even before a single dose of vaccine is administered.
She continues, âMany rural communities will only come forward if they have received a blessing or approval from the chief.
South African hospitals are now preparing for the country’s fourth wave of COVID-19 infections, driven by the recently identified and more highly infectious Omicron strain. Originally concentrated around Johannesburg and the capital Pretoria in Gauteng province, the fourth wave is only now beginning to spread to other more rural provinces.
Cases are increasing in the country but, so far, have not resulted in an increase in hospitalizations or deaths.
Yet healthcare workers told VICE World News that some hospital units in KwaZulu-Natal are already grappling with healthcare worker shortages as infected workers – though still in relatively good health – are forced to isolate themselves at home.
What Omicron means for the country’s rural areas is still unclear, but some experts are already worried about the impact of COVID-19 on the country’s rural health system.
Although the country has hired more healthcare workers to deal with COVID-19, Director of the Rural Health Advocacy Project, Russell Rensburg, warns that most of these positions have been assigned to urban areas which have likely been the hardest hit. affected by deaths from COVID-19.
âIronically, some of the investments in health that were made during COVID will negatively impact rural areas as these positions will be in urban centers because that was where the need was,â he says. âMove these posts to rural areas – and the crisis that awaits us now is going to be much more difficult to manage. “
The crisis, warns Rensburg, is that South Africa – like many African countries – is struggling to pay for the mammoth task of responding to an epidemic that no one saw coming and shows no signs of slowing down. The majority of South Africans, especially in rural areas, depend on the public health system, and the country’s health budgets are already struggling to fund some regular, non-COVID health posts.
âSouth Africa has been in debt over the past 10 years, and now the chickens are coming home to roost,â he warns. âThe government spends 25 cents of every rand on debt repayment. Income goes down and debt repayments go up – the amount of money available for public health spending goes down.
âPublicly funded health care – on which the majority of the country relies – depends on tax revenues,â Rensburg continues, âWe have a very serious situation. “