Immunisation programmes across the world generally focus on babies and their mothers, but rarely on adolescent girls. In Rwanda, an innovative partnership has put them at the centre of an effort to boost uptake of life-saving vaccines and other health services across the country. Are there lessons for other countries?

Gavi, the Vaccine Alliance, Girl Effect, an international non-profit using digital media to equip girls to make positive choices, and the Rwandan Government, started collaborating in 2016 on a project to increase awareness about HPV immunisation, enhance agency of young girls and enable communities to promote good health.

Cervical cancer is the most frequent cancer among women in Rwanda and the second most common in Africa, according to WHO. And despite being a preventable disease, it is also the deadliest. The Human Papilloma Virus (HPV) is behind almost all cervical cancers.

Rwanda had launched an ambitious vaccination campaign against cervical cancer in 2011, but despite high coverage, awareness around the disease remained low and misinformation and fear around the HPV vaccine widespread.

There are about 10% to 20% of children that vaccination programmes don’t reach, according to UNICEF, and two thirds of them live below poverty line

“Because the vaccine is for adolescent girls only, many parents and even health workers deducted that it was to make them unfertile,” said Frida Uwera, Girl Effect Rwanda Strategist. There were also rumours that the vaccine caused the disease or bad side effects. In addition, HPV is sexually transmitted and talking about sex is difficult in Rwanda.

“Gavi was used to focus on under two-year olds, but with HPV, we needed to engage adolescent girls. It was a new territory for us,” said Rachel Belt, Gavi Rwanda senior country manager.  “Girl Effect are experts in reaching that population consistently. They are trusted by adolescent girls and have such a deep reach in Rwanda.”

In 2011, Girl Effect had launched Ni Nyampinga, a multi-platform youth brand to help girls access opportunities and skills in education, health and economic empowerment, and challenge the perceptions and behaviours that hold them back. Produced by girls for girls, Ni Nyampinga is made up of a magazine, radio drama and talk show, digital platforms and a network of brand ambassadors and clubs in all 30 districts of the country. It now reaches 80% of the population with over half of them active consumers.

Girl Effect researched what prevented girls from getting immunized, then worked closely with the Ministry of Health to develop reliable and factual information to counteract these issues.  “We tested different formats and contents so that the messages were clear, simple and accurate, then we embedded them in our regular content and storylines on all our platforms,” said Uwera.

Full impact data is expected later this year, but preliminary data based on qualitative interviews show that girls who read the magazine and/or listen to the radio show are more likely to be aware of cervical cancer and have accurate information about HPV vaccine. “Infertility myths are still around, but girls are on the frontline dismiss them, telling their parents and young sisters,” said Uwera.

“We can already feel changes that would not have happened without the partnership,” said Dr Sibomana Hassan, the Ministry of Health’s person responsible for coordinating all immunisation-related activities in the country. “Feedback from Ni Nyampinga audience is a living evidence not only of real changes taking place today, but also potential changes in the future.”

A girl-centric strategy is an important factor in driving these future changes. The HPV vaccine is not given in isolation, but alongside other health services, such as nutrition and sexual and reproductive health. It is an entry point at a critical moment in a girl’s life, which can set her on a good health trajectory.  “More than 50% of Rwanda’s population is young, including today’s girls who are tomorrow’s mothers. These mothers will be able to make an informed decision about health as a result of their empowerment,” Dr Hassan said.

Lessons from the four-year $10m partnership, funded through Gavi and Girl Effect matching funds, are already informing a similar Gavi/Girl Effect approach in Ethiopia and Malawi, where HPV vaccine was introduced in December 2018 and January 2019 respectively.

Today, Rwanda’s HPV and routine childhood diseases vaccination programmes have achieved 95%-97% coverage. These rates would be striking in any country, but even more so in a post-conflict, post-genocide and low-income country. High-income countries, like France and the US, for example, have only achieved moderate coverage of the HPV vaccine.

Yet, there are still 3% to 5% of adolescent girls and babies to reach, and they are often the most vulnerable. In November 2019, the partnership embarked on a 13-month new phase to understand who these hard-to-reach people are and what are the persistent gendered barriers to, not only HPV, but also routine immunisation – something that vaccine programmes across the world have very little knowledge of.

“To reach last 5%, we really need to go deep and look at barriers for women who are very young or vulnerable with little support around them,” said Ilaria Buscaglia, Girl Effect Rwanda, Senior Qualitative Analyst.  “They might not see vaccines as important because they have so many other pressing issues to deal with. They might be teenage mothers, single mothers, women with disabilities or victims of domestic abuse.”  The partnership will then develop a bespoke communication strategy to connect and engage with them, the same way they did with HPV.

“We can already feel changes that would not have happened without the partnership"

The partnership is now building a body of evidence and toolkits so that Rwanda’s experience could be scaled up and shared with ministries of health in other countries.

Across the world, there are about 10% to 20% of children that vaccination programmes don’t reach, according to UNICEF, and two-thirds of them live below the poverty line.

”We want to focus our strategy for the next five year to reach those children who are being systematically missed today,” said Meghana Sharafudeen, Gavi Manager, global and country media engagement. “Most of them are likely to live in communities where other health services are also unavailable. We need to overcome the gendered barriers that prevent them from accessing routine vaccination and health services."

“Barriers are often specific to countries, but our work in Rwanda allows us to ask the right questions and collect the right data. Once we know ‘here are the three or four key gender barriers’, it is then easy for us to add these questions into our reviews of other countries and present them to their governments. Because reaching the last children is so central to our strategy, we need to have these conversations with governments that are missing children.” – Veronique Mistiaen

(Photo credit: Unsplash)