The weather was cold, windy and threatening to rain, but Sylvia Nyasuku had given her word to vaccinate a group of kids from a tea-picking families at Kajugangoma, a village some five kilometres off the Uganda-Democratic Republic of the Congo border. So the midwife, who is attached to Kirima Health Centre III in Uganda’s Kanungu district, slung her vaccine carrier across her chest and took the winding footpath towards the tea estate.

Close behind her, a group of village health teams (VHTs) and health advocates from the Innovation Programme for Community Transformation, or InPact-Uganda, followed. “Lots of mothers here will not bring their children to health facilities for immunisation because of poverty and other challenges,” said Nyasuku as she navigated the muddy footpath. “So, we have to go to them – to their workplaces.”

It had begun to drizzle, and that pleasant petrichor scent filled the air as Nyasuku and team reached the plantation. Rows of lush green bushes carpeted low-lying hills, and more than 30 women, wearing dirty clothes and scruffy headscarves, bent to pluck the plants’ leaves. Almost every one of the women had a baby strapped to her back.

Immediately Nyasuku and team set about erecting a makeshift vaccination centre on the edge of the tea plantation, while one of the VHTs hurried over to gather in the women.

No picnic

Nyasuku and her team number among a cadre of community health workers who move from home to home, and workplace to workplace, to find and vaccinate Uganda’s zero-dose and under-immunised children, protecting them from vaccine-preventable diseases (VPDs).

Communities around tea estates in Uganda’s districts of Kanungu, Kabale and Bushenyi harbour an outsize proportion of the country’s zero-dose burden – estimated at 3% – in significant part because the tea-workers’ settlements are necessarily remote from town centres, and consequently typically far from health facilities.

For instance, the Kajugangoma tea plantation that Nyasuku and her team visited today is seven kilometres from the closest health facilities: Kirima Health Centre III or Katate Health Centre IV. For parents with kids that need vaccinating, that means either walking for most of the day, or parting with 5,000 Ugandang shillings (US$ 1.37), more than a day’s earnings for many, for transport.

The tea estate communities also harbour under-immunised kids because of social challenges related to poverty and gender-based violence.

“Apart from the few individuals who own the tea plantations, the majority of the community live on less than a dollar a day,” said Loy Tukahirwa, a mother of four and VHT officer in Kajugangoma village. “The women will pick the tea leaves the entire day and earn 3,000 shillings (US$ 0.82). Off this money, they have to buy food, water, clothes and take kids to school. So, they may not understand when you ask them to take a day off work to take kids to health facilities for immunisation.”

Sowing change

But Nyasuku and team are giving the women another option by helping to take health and vaccination services directly to the mothers and the children wherever they are.

Funded by Gavi, through PATH Uganda, the team visits health facilities in the tea-growing districts and maps out surrounding communities that are located more than five kilometres from the nearest clinic.  Next, the health advocates work with VHTs to review the health facilities’ immunisation data and identify communities with the highest numbers of zero-dose and under-immunised children. Then they work with the health facilities and local tea plantation managers to bring vaccines directly to where women with immunisation-eligible children are at work.

“Gavi gives us the vaccines, the VHTs mobilise the mothers and we facilitate the health workers to vaccinate these children,” said Davis Byamukama from InPact-Uganda. “Sometimes we do house-to-house visits. Other times we organise outreaches, like today.”

“(Our strategy) is more like that saying… ‘If the mountain will not come to Muhammad, then Muhammad will go to the mountain,’” said Byamukama. “It is built on supporting health workers to identify and reach these vulnerable mothers and children wherever they are.”

A new leaf

Apart from this, the community health workers facilitate group psychotherapy to improve mental health in the communities.

“We know that stress, depression and other mental health challenges can determine whether a mother takes their child for immunisation or not,” said Jordan Agaba, a mental health lead at InPact-Uganda. “So, we sit with the community to understand their challenges. After this, we enrol mothers who qualify on a six-week group therapy, where they share their challenges and coping mechanisms.”

The interventions are helping. Nyasuku said health workers were finding and vaccinating more children than before. “For instance, today [during the outreach at Kajugangoma] we found children who had never been vaccinated and gave them BCG,” she said, referring to the tuberculosis vaccine. “We also found children who had received DPT1 [to protect them against diphtheria, pertussis and tetanus] and disappeared. We gave these DPT2.”

Emily Katarikawe, Executive Director for InPact-Uganda said door-to-door visits by community health workers had also helped to address anxieties about immunisation and built trust in vaccines. The interventions were slowly creating a ripple effect, where more parents took pride in ensuring their children were fully vaccinated, she said.

First flush

Indeed, immunisation coverage figures in several tea-growing sub-counties have leapt in recent years. According to figures from the Ministry of Health, coverage with DPT1, the first dose of the diphtheria, pertussis and tetanus-containing combo-vaccine, in Kirima sub-country has risen from 89% in 2020 to 129% in 2024, where the percentages above 100% reflect the discovery that there were more children to immunise than projected during planning. It’s the same for Nyabubare sub-county in Bushenyi district. Figures show that coverage for DPT1 there leapt up to 115% in 2020 and up again to 119% in 2024.

A lot of children were missing out on vaccination services because their mothers didn’t have money to transport them to health facilities… but when health workers find women at work, it eliminates every excuse.

- Elivida Kemirembe, chairperson for Mugongo cell

Dr Immaculate Ampeire, senior medical officer at Uganda’s National Expanded Programme on Immunization (UNEPI), said the community health workers have helped the country towards its target of reaching reducing the numbers of unimmunised children by 50% in the next five years.

Elivida Kemirembe, chairperson for Mugongo cell, one of the tea-growing communities in Kanungu district, said it helped when nurses and other community health workers found mothers at their workplaces.

“A lot of children were missing out on vaccination services because their mothers didn’t have money to transport them to health facilities… but when health workers find women at work, it eliminates every excuse.”

Back to Kajugangoma, Nyasuku says vaccines have had a palpable impact on childhood diseases on the tea estates. “For example, shots for rotavirus have helped us to control diarrhoea that was one of the leading causes of death in children below five years in the communities.”

Vaccines have also helped to control measles in the region, she said. Although the communities still experience sporadic outbreaks of the viral disease, the infections are largely not fatal because the measles-rubella vaccine has helped the children to develop immunity to fight off the virus.

This article is republished from VaccinesWork under a Creative Commons license. Read the original article. VaccinesWork is an award-winning digital platform hosted by Gavi, the Vaccine Alliance covering news, features and explainers from every corner of global health and immunisation.