Expanding Covid vaccine cover from hills to coast: Ground workers speak out

India successfully administered 100 crore Covid-19 vaccinations within nine months, and 200 crore vaccinations in just 18 months, despite the many challenges of the pandemic. This achievement is seen as a direct result of a wide range of partnerships which helped to support the country’s vaccination drive. One such high-impact initiative has been the MOMENTUM Routine Immunization Transformation and Equity Project, part of a group of innovative awards supported by USAID.

In India, the Project partnered with John Snow India Private Limited to contribute greatly to India’s (and the world’s largest) COVID-19 immunization success. Operational across 18 states & Union Territories, a hallmark of this Project has been the ability to forge partnerships that result in locally relevant, contextual solutions to overcome barriers for COVID-19 vaccinations across different states and regions. Since September 2021, 26 development organizations or sub-awardees were selected to build a strong on-ground presence in 298 districts.

In this interview, two sub-awardees – SAATHII (Solidarity and Action Against The HIV Infection in India) and MFM (Mission Foundation Movement) – talk about their association and experiences in supporting the Project toward its broader goal of increasing vaccination coverage in India for vulnerable communities at the last mile. Excerpts

Interviewee: Manish, Operations at SAATHI

The Momentum Routine Immunization Transformation and Equity Project looks, especially, to reach out to the vulnerable. Were there particular target groups you had in mind that you were looking to support via your interventions?

When we proposed interventions, we were looking at vulnerable groups as people living with HIV, the transgender community, people with disability and pregnant and lactating mothers as well. Of course, when we went into the field we did see a lot more groups within the districts where we worked which needed support; especially the indigenous communities who lived in the Hilly areas like Sirumalai in Madurai & Kalvarayan hills in Kallakurichi district. We visited the Kalvarayan hills in Kallakurichi as well, another remote area where the coverage has been very dismal. There were other nomadic groups as well. In Tamil Nadu, we have the Narikurava community, who make local artefacts, and rarely stay in one place. A misconception they have is that their immunity is very strong, nothing could affect them.

What kind of strategies did you adopt to overcome such challenges?

For instance, the fishermen in Cuddalore. A large number of these fishermen were identified by our team as being unvaccinated. The team visited them and spoke to the leader first about how best to get them vaccinated. We learnt that the only window we had was when they come ashore from the sea with their catch, and the fish have been segregated and sent off to the markets. That’s the best time! That is when the team visited with the support of their local leader.

In the Kalvarayan hills, where tribal communities live in remote areas in small groups, the team leveraged the time around festivals of the tribal communities – when they’d all be mostly available. In some areas the church priest helped by making Sunday announcements asking people to congregate for vaccines.

Can you talk about the problem of vaccine hesitancy on the ground and how you countered it?

A lot of misinformation is created leading to hesitancy even among the educated who believe what is shared via WhatsApp rather than communication by WHO or the Health Ministry of the country. We addressed hesitancy at individual level through interpersonal communications in groups; we tried leveraging folklore and local cultural events to disseminate accurate information. With the further support of the Project state team, we tried to amplify positive information dissemination: telling people the advantages of COVID-19 vaccinations. We used handouts for this at various gatherings, specially targeting festivals.

You mentioned pregnant and lactating women was a priority group. How did you engage with them and ensure they were vaccinated?

With pregnant and lactating mothers, there are these designated maternity days when we got doctors to speak to them and ensure vaccinations happens. We have done this in Puddukotai, Madurai, and Ariyalur., where health personnel visited the mothers and motivated them to get vaccinated.

We also did door-to-door vaccination for the women as we did for people with disability and the elderly community. With this group, we have emphasized with the help of medical personnel on how many mothers have been vaccinated without any adverse effects of vaccination. Communicating patiently with the pregnant mothers has been our core strategy for this community.

Can you talk about your association with the Momentum Routine Immunization Transformation and Equity Project?

We are fortunate to be partnering with the Project and with its country implementation partner JSI, and that too in a state like Tamil Nadu where we have had our longest organizational presence. We are proud that we could contribute to the vaccination efforts of the country with technical support from the Project state team as well as the central team – this ensured that we could quickly establish our relationship with the state nodal officers and allied nodal departments. The result has been that ten lakh doses have been facilitated through this Project. Considering we covered eight districts within a short period of time, we do feel proud of this achievement. I strongly feel that this could happen because of multiple factors one of which is that we got a very dedicated team in place.

How long has your collaboration been?

We began our efforts in December 2021. But we started on field work in February and March 2022. Since then, till 6th October, 2022, we have reached lakhs of people for all the three doses, starting from 12 years and above. We have almost reached an equal number of male to female, with coverage of 49% for males and 51% for females.

Interviewee: Liandimvung, Project Coordinator (Community Health, women empowerment)

As part of the Momentum Routine Immunization Transformation and Equity project, what areas have you focused on?

For the MOMENTUM Routine Immunization Transformation and Equity Project, we worked in Mizoram with the objective of increasing the demand, distribution and uptake of the COVID-19 vaccination and also to strengthen the capacity at the state level as well as the district level and also ensure last-mile delivery. We worked in 3 districts as part of this project in Mizoram – Lunglei district, Mamit district, and Kolasib district.

Considering there is a high tribal demography in the region, were there specific problems you were looking to address? What measures did you take to counter them?

Mizoram is a tribal-populated state and vaccine hesitancy is very prevalent among the community. In line with the Project objectives of reaching out to the vulnerable as well as covering the hard-to-reach areas, we worked closely with the Bru and Chakma communities in the state. Bru and Chakma communities are often socially excluded, and have been hesitant toward COVID-19 vaccinations. They were a priority group for us, and the Project gave us the opportunity to engage them. These communities live in very remote areas as well – continuous sensitization and mobilization is needed to gain their trust.

The terrain is challenging in the state – what problems arose because of it and how did the team overcome them?

Mizoram topography is difficult, and it has high rainfall areas. There are some areas where there is no road connectivity. We have a Vaccine Express which goes to every village. But still there are places where the Vaccine Express cannot go – areas especially where the Bru and Chakma live. Our team travelled 5-10 km in such cases by foot, with the local health teams. The teams had to walk and carry the vaccine boxes and all the required materials with them, sometimes for upto 12 or 13 hours to reach some villages

Could you describe what the Vaccine Express is?

The Vaccine Express is a mobile van where we have a full team of local workers including healthcare personnel. This is mainly a four-wheel drive because normal vehicles cannot access many place These vans also help to reach persons with disabilities. Thus, it’s one of the biggest support from the Project that benefited the community.

What informed your communication strategy overall?

Before developing any communication strategy, we tried to understand the context. What are the kinds of misinformation currently going on? What are the local people’s beliefs? What cultural markers influence them? We ensured that we engaged local vaccine ambassadors as well as health workers. This helped us understand who we would be targeting and informed our messaging. Only after such assessments, did we develop communication strategies according to the community needs – from posters, flyers to audio-visual material. We ensured collaboration with and the support of district immunization officers, medical officers and Block Medical Officers.

What has been the vaccine uptake like?

We have vaccinated 7,059 doses for 1st dose and for second dose we have administered 11,458 doses. To be specific for the Bru and Chakma communities; we have vaccinated 1,726 Brus and 2,443 Chakmas till date. We have also taken up special vaccination campaigns, for instance, for the government’s Har Ghar Dastak campaign we have vaccinated 4,689 beneficiaries. This has all been achieved in less than a year, with a lot of support from the Project.

Can you talk about the importance of partnerships at the last mile for development work, and how it ensures stronger health outcomes at the grassroots?

The work that we did at the field is something that we cannot do on our own. It inevitably needs good partnerships. For example, we have a strong partnership with the health department who supported us and guided us in whatever way we needed. At the ground level, specifically in Mizoram, we partnered with organizations such as Young Mizo Association as well as village council members. The village council members helped us in preparing the microplan at that community level. How we will visit the village, who we can target and how, etc where some of the aspects covered in the plan. Faith leaders and community leaders also helped in reaching out to the population.

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