A Promising Start: South Sudan’s Malaria Vaccine Rollout Hinges on Sustained Investment and Community Engagement

Photo credit: Poni Joyce

On July 16, 2024, South Sudan became one of the first twenty countries in the world to introduce the malaria vaccine into its national routine immunization program. In a country where malaria is endemic and responsible for nearly half of all deaths among children under five, the R21 malaria vaccine offers a critical new tool in the effort to save young lives.

While the introduction marked a major milestone, providing full coverage, which requires four doses of malaria vaccine, has proven challenging. Initial assessments by UNICEF showed a promising 77% of surveyed caregivers were willing to accept the vaccine. However, delivery and uptake still fall well short of the national goal of 80% coverage by 2025, with current declining coverage hovering around 35% for the first of four doses of the malaria vaccine (annualized at 53%). Closing this gap will take more than stocked supply chains and trained health workers. It will require long-term political commitment, sustained financing, and strong community partnerships and mobilization efforts, particularly for scaling up the malaria vaccine in July 2025 in the rest of the counties of South Sudan.

Laying the Groundwork

The Ministry of Health, with support from Gavi, UNICEF, WHO, JSI, and other partners, rolled out the vaccine in six states with the highest malaria burden and child mortality. JSI’s role centered on building the foundation for success—developing and deploying training materials with health workers, coordinating stakeholder engagement, and documenting implementation challenges, lessons learned, and emerging best practices.

UNICEF supported vaccine procurement and cold chain logistics, facilitating the delivery of 645,000 doses by May 2024. Between August and November 2024, during the initial assessment period, vaccine stocks were available at national, state, county, and facility levels.

In preparation, 1,934 health workers were trained, including 1,102 vaccinators and 551 social mobilizers, using materials developed by JSI and approved and adopted by the Ministry of Health. This helped equip the workforce to deliver the new vaccine effectively in the first months of introduction. With JSI’s support, the Ministry of Health established a coordination mechanism with the partners and stakeholders at the national and subnational level and with the implementing states, which was instrumental for launching the vaccine and monitoring, providing technical guidance to troubleshoot implementation bottlenecks to MoH and partners at state and county levels.

Implementation Setbacks: Workforce and Funding Gaps

The malaria vaccine introduction comes at a time of health system shifts. In July 2024, South Sudan’s routine immunization program transitioned from one donor mechanism, the Health-Pooled Fund, to another, the World Bank’s Health Sector Transformation Project. This transition affected critical components of the vaccine rollout, most notably supportive supervision, community outreach, social mobilization, and risk communication efforts. There were also outbreaks of other vaccine-preventable diseases including yellow fever, measles, and poliovirus (cVDP2) that constrained the ability of the MOH and partners to provide additional support to malaria vaccine introduction monitoring. Security risks and flooding exacerbated these challenges as both caregivers and health care workers struggled to reach health facilities.

Caregiver, health facility, and outreach constraints made the provision of all four doses challenging. Among children who received the first dose of the malaria vaccine, 34% have received a second dose, and only 9% have received the third dose.

Key Lessons

While protection against malaria is highly valued by the health program and clients in South Sudan, the rollout of the malaria vaccine demonstrates that introducing a new vaccine is not just about availability. Vaccine introduction requires stable and accessible systems, environments that facilitate uptake, and positive relationships. This experience reinforces several critical lessons to improve the current malaria vaccination program and its scale up in the rest of the country:

• Sustained financing is essential for continuity of services and program quality, particularly for day-to-day subnational operational needs.
• Health worker support and supervision must be prioritized, especially during health system transitions.
• Community engagement is vital. Social mobilizers play a fundamental role in connecting families with care and building and sustaining trust and uptake in vaccination.

The malaria vaccine is one essential part of a package of public health services. Insecticide-treated bed nets, effective treatment, and integrated preventive measures must continue to complement vaccination efforts. With continuing support from the Ministry of Health, sustained investment and technical assistance from partners like JSI, this new vaccine can become a powerful addition to South Sudan’s malaria prevention strategy—and a key contributor to reducing preventable child deaths.