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A new generation of Mozambican children is growing up healthier than ever, supported by high rates of routine immunization. Child mortality has dropped dramatically, life expectancy has climbed and families are seeing the benefits in longer, healthier lives. However, malaria vaccination has lagged other health interventions, particularly beyond the first of the four doses recommended for full immunity. The country’s public health transformation gained fresh momentum in August 2024, when Mozambique introduced the R21 malaria vaccine in Zambézia Province.
The R21 malaria vaccine, developed by the University of Oxford and Serum Institute of India, is one of the tools in the fight against malaria. By incorporating R21 into its routine immunization program, Mozambique aims to protect hundreds of thousands of children each year, reinforcing decades of progress in child health. We won’t know the full extent of the new vaccine’s impact until the end of 2026.
Zambézia was chosen for the initial rollout because it is the Mozambican province with the highest prevalence of malaria and child mortality associated with malaria, and it has some of the lowest rates of routine immunization more broadly.
Understanding Communities: The BeSD Survey
Following the initial rollout of the malaria vaccine, VillageReach, under the leadership of Mozambique’s Ministry of Health and in collaboration with key partners, conducted a Behavioral and Social Drivers (BeSD) survey across four districts of Zambézia Province (Alto Molocue, Maganja da Costa, Mocuba and Molumbo) to gather perspectives on community attitudes, motivations and concerns around vaccination to inform a more effective and inclusive strategy for the next stage of the R21 rollout.
The survey generated insights from a wide range of stakeholders, including vaccine technicians, health facility managers, provincial and district EPI leads, community health workers (CHWs), local leaders and secretaries, and caregivers of children aged 6–11 months.
The BeSD study applied WHO’s behavioral framework, using surveys, focus group discussions and key informant interviews. It revealed that 95% of respondents had heard of malaria and could identify its symptoms. However, 21% of children had not slept under a net the previous night due to lack of access.
Awareness of the malaria vaccine was encouraging, with 83% of caregivers having heard of it, often through radio, health facilities or community leaders. Yet access barriers such as wait times, unavailability, transportation and costs were widespread, particularly in Maganja da Costa where 70% of caregivers reported difficulties.
Despite these barriers, 96% of caregivers expressed willingness to vaccinate their children and confidence in information from health workers was high. Importantly, gender roles influenced uptake: 31% of mothers needed permission from fathers or household heads to vaccinate. These insights underscored that building vaccine demand is not simply about information, but it requires tackling systemic and social barriers at once.
Focusing on the BeSD Findings
Key priorities emerging from the study included strengthening vaccinator training, streamlining service delivery logistics, expanding social mobilization efforts and improving data quality for decision-making.
According to Nelio Americo Jaquissone, District EPI Manager at Alto Molocué District Services for Health and Social Action (SDSMAS), “The BeSD report will help identify the factors driving vaccine uptake.” In his view, key recommendations to take forward include enhancing the availability of the malaria vaccine at health facilities and social mobilization around the importance of vaccination.
Mr. Jaquissone’s SDSMAS counterpart in Maganja da Costa, Oriel Manhique, appreciated the thorough demographic information provided in the report, which highlighted disparities in malaria vaccine uptake. He would like to see increased resourcing to enable follow-up with children who have received their initial malaria vaccine doses, particularly from mobile brigades.
What’s Working and What Needs to Change
The BeSD report also highlighted strategies already making a difference. Mobile vaccination brigades improved completion of all four doses compared to fixed facilities, and caregivers expressed interest in SMS reminders to prevent missed doses. Collaboration with community and religious leaders was proving effective in dispelling misinformation and normalizing malaria vaccination, particularly when reinforced with caregiver testimonials and radio messaging.
At the same time, systemic improvements were essential. Health workers requested earlier and more comprehensive training, including guidance on managing side effects and communicating with caregivers. Consistent vaccine availability, larger refrigerators to expand cold chain capacity and adequate recording tools were repeatedly cited as priorities for sustaining demand and preventing missed opportunities.
Moving Forward
The BeSD findings show that expanding access to the malaria vaccine is about more than supply. It is about building trust, addressing gender dynamics, improving service delivery and reinforcing social norms that protect children’s health.
Lessons learned in Zambézia are informing Mozambique’s plans to expand malaria vaccination to additional provinces, aligning with the National Malaria Strategic Plan (2023–2030). The report stresses the importance of continuous monitoring, routine data audits and applying RED/REC strategies to adapt community-driven solutions.
VillageReach is proud to support the government in this effort by documenting and applying learnings from the vaccine rollout in Zambézia to strengthen Mozambique’s immunization system more broadly. While it is early days, these insights may inform malaria vaccine introduction in other countries.
The BeSD report reminds us that this progress rests on the dedication and care of health workers, the trust of caregivers and the commitment of communities to give every child a shot at a healthier future. By addressing barriers to demand, improving access, strengthening community education and investing in health system infrastructure, the R21 vaccine can reach its full potential.