# Recommendations to mitigate barriers to uptake and delivery of a four-dose malaria vaccine schedule: insights from the MVIP’s qualitative evidence

## TL;DR

This paper provides recommendations to improve the delivery and uptake of a four-dose malaria vaccine based on insights from pilot programs in Ghana, Kenya, and Malawi.

## Contribution

The paper offers actionable insights and recommendations to address barriers in implementing a four-dose malaria vaccine schedule.

## Key findings

- Many children missed doses due to challenges in vaccine acceptance and delivery.
- The paper highlights guidance and tools to help track and manage the four-dose schedule.
- Recommendations aim to complement existing materials for vaccine expansion.

## Abstract

Malaria vaccination was piloted in selected areas of three countries to produce evidence that would inform global recommendations on the public health use of the RTS,S/AS01E (RTS,S) malaria vaccine and to inform guidance for countries planning to introduce the vaccine into childhood immunization systems. This paper focuses on challenges to the uptake and delivery of a four-dose RTS,S schedule, presents actionable insights into qualitative data from the 2019–2023 Malaria Vaccine Pilot Evaluation in Ghana, Kenya, and Malawi, and presents recommendations to address barriers to vaccine uptake.

This paper draws on published qualitative data from the three pilot countries and unpublished expert analysis. It draws on findings previously reported in publications from a qualitative longitudinal study, the Healthcare Utilization Study (HUS), conducted in a subsample of communities where RTS,S was introduced during the pilots. The study elicited perceptions from caregivers of eligible children about the vaccine alongside other relevant topics, such as their use of vaccination services. Interviews with health workers focused on their evolving perceptions about the vaccine and experiences integrating its delivery into routine immunization. Technical experts involved in the vaccine pilot and implementation managers from the pilot countries provided insights from their experiences. This feedback helped validate both the findings and the potential practicality of recommendations for scaling up delivery.

Despite good acceptance of the vaccine, many children missed some or all doses due to overlapping challenges to acceptance and delivery of the four-dose schedule. Highlighting the barriers to uptake, the paper discusses guidance, tools, and materials that may help programme staff develop strategies, plans, and materials, including strategies to address the complexity of the schedule and to track four doses for individual children.

Adding a four-dose vaccine to a crowded routine immunization schedule presents challenges, as seen during the pilots. The malaria vaccine experience and several studies have provided guidance and tools to support malaria vaccine expansion in the three countries and introduction of the vaccine elsewhere. The observations and recommendations in this paper are intended as a complement to the wide range of materials, guidance and tools already available.