Background

Namibia is recovering from a devastating 3^rd wave which saw the country reporting 1 278 deaths per million [1]^,[2]  in early August comparative to that of South Africa.  In anticipation for a possible 4^th wave, vaccination against COVID-19 is prioritized to minimize the impact experienced by the health systems and society at the peak of the 3^rd wave.  During the 3^rd wave the health system became overwhelmed with, at times, over 100% bed occupancy. Oxygen supplies were exhausted and health workforce overstretched resulting in increasing infection of Health Care Workers  (HCW) as they were saving lives and sadly some lost their lives.

The first ever COVID -19 vaccination campaign was launched in March 2021, initially in 2 of the 14 regions, rolling it out to the rest of the country in April 2021. By July 2021, after a period of 4 months and regular review and feedback on individual level by regions, MoHSS, observed a relatively slow uptake for vaccination in general, averaging only about 3000, far from reaching the projected daily target of 10.000 vaccinations.

The MoHSS projected a target population of 1.501.041 (60%) of the total population to be vaccinated to reach herd immunity. As at the end of July a total of 207 950 Namibians were vaccinated, representing a total of 159 881(10.6%) for first dose and only 48 069(3.2%) second dose.

This represented a low uptake and lacking behind with 7% in reaching the 10% target for the end of September 2021. Factors contributing to the low uptake in Namibia included the circulation of rumours in communities, concerns over the safety and efficacy of the vaccines, and vaccine hesitancy amongst HCWs.   

International studies in 28 nationally representative samples, found that as the pandemic progresses, the percentage intending to vaccinate decreased and the percentage intending to refuse increased. Pooled data between June and October 2020 suggest that only 60% intend to vaccinate, while about 20% intend to refuse. Intensions varied substantially between samples and countries, key findings associated with low uptake/less likely to be vaccinated included being female, lower income, lower education and ethnic minority. A WHO KAP survey (May 2021) states that more than one third (35%) of the respondents were unwilling to take the vaccine with the main reason being that they ‘didn’t trust the vaccine’.   

Intervention

In order to address the persistent hesitancy, the Namibian government through the Ministry of Health and Social Services (MoHSS)  and  Ministry of Information, Communication and Technology (MICT)   with support from  UN agencies (WHO, UNICEF, UNESCO, UNFPA, UNAIDS), CDC and other partners redesigned a comprehensive strategy to  improve vaccine acceptance and increase access to vaccination sites in all health districts.  A vaccine communication strategy was redrafted and a mass media campaign on vaccination launched under the tagline ‘Get Vaccinated! Help Kick COVID-19 out of Namibia’.  Communication materials were produced and translated in local languages for radio, television and print media.  Regional and community leadership were especially engaged as key influencers for vaccine uptake.   MoHSS at regional and district levels partnered with these leadership to increase awareness activities in different communities and provided integrated outreach and vaccination services.  In some regions these integrated services would include the provision of psycho-social support services to cater for those severely affected by COVID-19. Government also conducted roadshows to all 14 regions using local artists and influencers to intensify mobilization for vaccine uptake.  

 In addition, MoHSS established a more focused forum to strengthen weekly monitoring of vaccine uptake as well as creating a platform for inter-regional learning and exchange of best practices and challenges. This forum is guided by terms of reference (TOR) and a reporting template to ensure consistency in weekly follow up and allow for immediate supportive interventions where there are challenges and gaps.  The platforms also enable frequent and consistent communication between national and regional levels which is crucial in any outbreak response.  Regions provided weekly updates on stakeholder and community engagement and sensitization, consistent review of plans to support low performing districts and reach for uptake, vaccine stock management, AEFI case management and vaccine data management. Weekly reports highlighted the achievements and challenges and renewed strategies to scale up and address challenges, including specific ongoing interventions to address the low uptake. 

The regional coordination forum conducted a total of 8 virtual meetings from August to September with a 70-80% regional/district representation to provide for regional interaction, guidance and support. Weekly reports were summarized and shared amongst all regions to have a comprehensive view of the vaccine rollout in the entire country and provide for learning opportunities from best practices.

Regional strategies to increase low uptake included:

• Providing virtual training and mentoring for more than 500 HCWs on vaccination, cold chain and AEFI case management.
• Providing onsite mentoring as part of support visits to priority regions.
• Developing own forms and processes to create a system for pre-booking in an effort to increase demand, reach targets as well as ensuring that multidose vaccines are utilized effectively to reduce and minimize vaccine wastage.
• Mobilizing communities through various media on a regular basis at operational level
• Engaging traditional and government leaders to serve as ambassadors and influencers to help address rumours and vaccine hesitancy.
• Forming of strategic alliances with other line ministries, private health services, business- people, farmer’s associations, non-governmental organizations, faith-based organizations and community-based organizations (CBOs) to increase access and uptake for vaccination. (Pension pay-out providers and drive-thru vaccination services)
• Extending vaccination services to include weekends and increase vaccination sites based on demand and reaching out to ‘Hard to reach” and
• Redefining target populations in different catchment areas to monitor daily, weekly and monthly targets.

 Results

The meetings provided a unique opportunity for multi- regional interaction to review performance, take stock of current practices and develop improved strategies. The sharing of best practices facilitated the implementation of successful practices and the country exceeded the target of 10% vaccination by the end of September 2021, at 11.5%.

The onsite initiatives for pre booking were applauded and encouraged, the MoHSS and Ministry of Information and Communication Technology (MICT) have engaged the local telecommunications network (Make the connection- MTC) to review /consider the potential for a much more robust approach to support vaccination sites to create demand and access to improve targets reaching the community through mobile technology.

Forming of strategic alliances rubbed off well from region to region and created the demand for improved engagement in all 14 regions, with 2 more regions establishing drive-thru centres, a unique approach with private sector support, reaching not only the affluent populations in Windhoek at its inception, but branching out to the most vulnerable in suburbs (Katutura in Windhoek) and other towns in the coastal area (Erongo/ Swakopmund) and central area (Otjozondjupa/ Otjiwarongo) of Namibia.

• As at the end of July a total of 20, 950 Namibians were vaccinated, representing a total of 159, 881(10.6%) for first dose and 4, 069(3.2%) second dose, also referred to as fully vaccinated.
• End of August a total of 329,063, representing first dose of 213,438 (14.2%) and second dose 115,624 (7.7%)
• End of September a total of 441,921, representing first dose of 269,215 (17.9%) and second dose 172,706 (11.5%)

Consistent weekly review and updates culminated in the plan for a national vaccination campaign to further boost coverage and reach the unreached, the hesitant, including those who need to return for second dose. The campaign will include integrating a national roadshow to mobilize communities to come out in numbers to reach a total of 150.000- 400.000 people in Namibia, getting the country well on the road in reaching the projected target of 40% by December 2021.