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Tag: Kate O'Brien

  • 50 years of the Expanded Programme on Immunization

    50 years of the Expanded Programme on Immunization

    In two articles published during the fiftieth year of the World Health Organization’s Expanded Programme on Immunization (EPI), Samarasekera and Shattock provide valuable insights into EPI’s remarkable impact on reducing childhood mortality and morbidity since its launch in 1974.

    Shattock et al. present a detailed quantitative analysis of the lives saved and health gains attributed to vaccination.

    They estimate that “since 1974, vaccination has averted 154 million deaths, including 146 million among children younger than 5 years of whom 101 million were infants younger than 1 year.” 

    The authors further emphasize the long-term benefits of vaccination, noting that “for every death averted, 66 years of full health were gained on average, translating to 10.2 billion years of full health gained.”

    These findings underscore the transformative impact of the Expanded Programme on Immunization on global health outcomes.

    Bill Moss of the International Vaccines Access Center (IVAC) calls this “one of humankind’s greatest achievements”.

    Inherent uncertainties based on the modeling approaches, data limitations and gaps, and challenges in attributing causality over a 50-year time horizon do not diminish their significance.

    Fresh challenges

    Samarasekera highlights several fresh challenges as EPI moves into its next 50 years:

    1. COVID-19 pandemic disruptions: The pandemic has led to 67 million children globally missing out on one or more vaccines. This has resulted in outbreaks of vaccine-preventable diseases, with measles outbreaks being reported in twice as many countries in 2023 compared to 2022. Due to pandemic disruption, many unimmunized children are now older than 2 years, requiring new approaches to reach them and prevent further outbreaks.
    2. Sustainable funding: Countries are facing challenges in sustaining funding for immunization programs due to debt crises, conflicts, and climate change.
    3. Improving collaboration during emergencies: There is a need for quicker access to vaccines and better coordination among stakeholders during humanitarian crises and outbreaks.
    4. Reaching the “last child”: Challenges persist in reaching children in conflict areas, active war zones, and those facing humanitarian crises, with immunization coverage in these settings being as low as 50-60%.

    While both articles recognize the urgent need to address these setbacks and reach underserved populations, they tend to emphasize the role of global agencies and donors in driving progress.

    For example, Samarasekera highlights the importance of initiatives like Gavi, the Vaccine Alliance, which was established in 2000 “to close the equity gap in access to vaccines,” and the Accelerated Development and Introduction Plans, which “expedited vaccine introduction in Gavi-supported countries.”

    While global plans and funding have been – and remain – undoubtedly crucial, this begs three questions:

    How to carry out such coordinated action and advocacy?

    Who will do it?

    What, if anything, should be different, compared to what was done in the past?

    Can we assume deployment?

    Both articles acknowledge that today’s challenges are different, and that immunization strategies should be grounded in local realities.

    Samarasekera’s report suggests exploring ideas such as involving community health workers more effectively, introducing newly approved vaccines (e.g., for malaria), and innovating vaccine delivery methods (e.g., microarray patches, single-dose vaccines).

    Ephrem T. Lemango, for example, emphasizes the role of health workers : “They are the most trusted source of information” for communities. “If we can skill these community health workers to vaccinate, provide them the required vaccines, then the likelihood of reaching the last child could be much more imminent”.

    Samarasekera also quotes O’Brien, who stresses that “every government that has had backsliding needs a plan, and most governments have made a plan and are starting to deploy. We have a very narrow window to get this completed.” 

    Neither article delves deeply into the specific strategies or mechanisms that connect global policy and funding to local action.

    Can “deployment” be assumed?

    There is wide recognition that local adaptation is a key challenge.

    This is most obvious in zones of armed conflict or when faced with the breakdown of trust in vaccines or government

    At the end of the day, it is health workers at the local levels that get the job of vaccination done.

    They are also the first to see epidemic outbreaks and to recognize changes in community trust.

    Does the future of vaccination require new ways of thinking and doing to adapt or invent strategies to lead to improved, sustained health outcomes?

    Global advocacy for community health workers to be paid is undeniably important.

    But paid to do what, how, and with what degree of recognition and support of their capacities, leadership, and expertise?

    This is where learning from the Movement for Immunization Agenda 2030 (IA2030) may offer useful insights that complement the top-down, global-level efforts emphasized in the articles.

    What is the Movement for Immunization Agenda 2030 (IA2030)?

    Launched by the Geneva Learning Foundation in March 2022, the Movement is a global network of over 10,000 health workers from 99 countries who have pledged to work together to achieve the goals of the Immunization Agenda 2030, the global strategy adopted by the World Health Assembly in 2020.

    Through peer learning and locally-led action, IA2030 members are sharing experiences, identifying root causes of immunization challenges, and implementing corrective actions tailored to their specific contexts.

    What does that actually mean?

    Wasnam Faye, a Senegalese midwife, moved the needle of vaccination coverage in a poor-performing remote health outpost from 8% to over 80%.

    How did she do it?

    At Teach to Reach, she met a doctor from the Democratic Republic of Congo who shared his EPI know-how with her, over WhatsApp.

    She then invited and trained caregivers to become peer educators, also building on what she heard at Teach to Reach.

    She then realized that she could speak about HPV vaccination for their daughters to mothers who came for cervical cancer screening.

    In global health, individual case studies and lived experience are often dismissed as anecdotal evidence.

    Each edition of Teach to Reach connects over 15,000 health workers, who share experience around their local challenges.

    At that scale, the cumulative insights gained take us beyond anecdotes and enable us to document how change happens at the local levels.

    Watch: Teach to Reach Insights Live with Orin Levine

    Rethinking immunization’s learning culture: Capacity for change, innovation, and risk

    To catch up and achieve the goals set for 2030, these articles suggest that a combination of increased funding, political commitment, and innovative strategies will be needed.

    It is important to recognize that top-down control and directive management appear to have been key to how immunization programmes achieved impressive results in previous decades.

    This explains why some EPI stakeholders may have an innovation challenge: why risk making changes or consider new models? 

    Addressing these underlying issues may require strengthening learning culture.

    “Learning culture” is a new concept in global health that provides the missing link between learning and performance.

    It measures the capacity for change and the leadership to recognize and support that capacity over time.

    That requires sustained financing, including specific funding required to test and scale new models and approaches. 

    But who will risk funding new ways to tackle the challenges facing immunization programs, such as weak health systems, inadequate infrastructure, and community trust?

    References

    Faye, W., Jones, I., Mbuh, C., & Sadki, R. (2023). Wasnam Faye. Vaccine angels – Give us the opportunity and we can perform miracles. (IA2030 Case study 18) (1.0). The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.7785244

    Jones, I., Eller, K., Mbuh, C., Steed, I., & Sadki, R. (2024). Making connections at Teach to Reach 8 (IA2030 Listening and Learning Report 6) (1.0). Teach to Reach: Connect 8, Geneva, Switzerland. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.8398550

    Jones, I., Sadki, R., Brooks, A., Gasse, F., Mbuh, C., Zha, M., Steed, I., Sequeira, J., Churchill, S., & Kovanovic, V. (2022). IA2030 Movement Year 1 report. Consultative engagement through a digitally enabled peer learning platform (1.0). The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.7119648

    Samarasekera, U., 2024. 50 years of the Expanded Programme on Immunization. The Lancet 403, 1971–1972. https://doi.org/10.1016/S0140-6736(24)01016-X

    Shattock, A.J., et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. The Lancet S014067362400850X. https://doi.org/10.1016/S0140-6736(24)00850-X

  • A round table for Immunization Agenda 2030: The leap from “bottom-up” consultation to multidimensional dialogue

    A round table for Immunization Agenda 2030: The leap from “bottom-up” consultation to multidimensional dialogue

    They connected from health facilities, districts, and national teams all over the world. 4,769 immunization professionals from the largest network of immunization managers in the world joined this week’s Special Event for Immunization Agenda 2030 (IA2030), the new strategy for immunization, with 59 global and regional partners who accepted the invitation to listen, learn, and share their feedback. (The Special Event is now being re-run every four hours, and you can join the next session here.)

    “My ‘Eureka moment’ was when the presenter emphasized that many outbreaks are happening throughout the globe and it is the people in the room who can steer things in a better direction”, shared a participant. “This gave me motivation and confidence that by unifying on a platform and by discussing the challenges, we can reach a solution.”

    Two of the top global people accountable for executing this new strategy, WHO’s Ann Lindstrand and UNICEF’s Robin Nandy, were in attendance. “With such commitment”, said Robin Nandy, “I am confident that we can achieve the goals of IA2030. Let us be mindful of the importance of convenient and high quality services delivered by a well informed workforce, which you all embody.”

    Hearing “invaluable insights”, Ann Lindstrand recalled that “IA2030 was developed with thousands of immunization stakeholders like you. It reflects exactly what you are telling today. I am encouraged to hear your analyses and ideas to face our common challenges.”

    Indeed, in developing Immunization Agenda 2030 intended to be “adaptive and flexible”, global partners employed a “bottom-up co-creation process”, described as “close engagement of countries to ensure that the vision, strategic priorities and goals are aligned with country needs.”

    There is, however, a risk of confirmation bias. Staff from countries do their best to carry out what they have been asked to do. In the conventional top-down hierarchical system, global recommendations are adopted by ministries of health that then command staff to execute them. If the system remains overly rigid, staff who want to keep their jobs are likely to confirm and comfort the assumptions of the higher-ups whose vision they have been tasked to implement, no matter the depth of the chasm between these assumptions and reality.

    During the Teach to Reach Accelerator conference in January 2021, Kate O’Brien, the director of WHO’s Immunization Department, pointed out that the term “bottom-up initiative” does not call into question existing hierarchies: “I don’t like the sort of hierarchy, about this is the bottom and this is the top, it has a certain sort of power element to me. […] I think leadership is about sitting around a table with a group of people, and drawing the best ideas from everybody who’s sitting around that table, wherever they come from.”

    Of course, immunization programmes have a strong technical dimension that require standardization. There are critical elements required for safe and effective vaccination. For example, WHO now organizes weekly didactic Q&A webinars (with Project ECHO, a fascinating organization of doctors exploring new ways to learn, and TechNet-21, a pioneering digital platform for immunization) that do the job of transmitting information to people involved in COVID-19 vaccine introduction. However, we know that information is necessary but insufficient to lead to the effective localization and application of standards. 

    As Kate O’Brien explained, “we need people to feel like they have the authority and are empowered to lead change in their community, in their programme, at the most local level, understanding what the goal is and what the targets are, taking those critical things that really cannot be compromised and adapting all around that.”

    The IA2030 framework is, according to its global custodians, “designed to be tailored by countries to their local context, and to be revised throughout the decade as new needs and challenges emerge.” In line with this vision, global partners are hoping to foster a “groundswell of support” or even a “social movement”, to ensure that immunization remains high on global and regional health agendas in support of countries.

    Alicia Juarrero, whose research focuses upon complex systems’ models of neural processes involved in proto-moral, moral and ethical cognition, emotions and behaviors, has made the compelling point that requires us to restructure what she calls the “space of possibility”. Continuous dialogue enabled by digital technologies can cut across hierarchies and borders to help create such a space. This represents a logical and constructive shift from “bottom-up” toward what Ian Steed has called multidimensional dialogue.

    Such a dialogue is likely to be different from what global partner staff are used to. It may be interesting, yet feel somehow illegitimate, if only because challenging the status quo may not be in their job description. Some may question its relevance. “This is just not how we do things in immunization,” is how one partner rebuked us in private. Others may even feel threatened, choosing to ignore or dismiss it, even if their organization’s mission is to support countries and people who deliver vaccines. Certainly, what is emergent is far from perfect and requires continued improvement to be truly inclusive of all voices and stakeholders needed to achieve the immunization goals. Nevertheless, participants in this week’s global round table collectively expressed the feeling of empowerment that stems from being connected in a global community for action. Combined with active presence and strong support of organizational leaders, it is moments like these that can spark new consciousness and could foster the birth of a movement.

    Image: Rainbow above the clouds. Personal collection.