Author: Robert Steinglass, November 19 2014 - A man walks into a hospital. Finding the floors dirty, he demands to see the in-charge, who protests: “Impossible, sir, we’ve hired three sweepers.”
Of course, we instantly recognize the absurdity; and yet such an unbalanced focus on inputs - or stuff - frequently dominates our thinking as to the challenges standing in the way of healthy outcomes.
Do these sweepers understand their role and its importance, have they been instructed in how to perform their duties, do they have brooms, are they supervised and supported to do their jobs well, are they paid on time or even at all, and are they recognized for doing a good job and guided on how to improve?
Stuff and more stuff
The "if you build it, they will come" school of development studies should hardly need reminders that the provision of bed nets, water pumps, or latrines - or even brooms - is rarely sufficient. True, the absence of such things can doom a program from the start, but “access” to these things certainly provides no guarantee of effective use.
If access alone was the issue, the percentage of women breastfeeding their babies exclusively for six months wouldn’t be less than 50 percent in every region of the world.
The overriding focus on vaccine access inclined us to believe that solutions lie in pouring more stuff - vaccines, refrigerators, etc. - into systems that are often dysfunctional, sometimes accompanied by inadequate investments in health systems strengthening. Unlike bed nets, which can be distributed once and last a family a long time, infants need timely vaccination five times before exposure to disease.
Thinking beyond access
Possibly for easy external consumption, framing the challenge as one of access to vaccines has muddled our understanding, oversimplified the challenges and diverted us from formulating more complete and robust solutions. Having World Health Organization prequalified vaccines on the global market, global policies on vaccines, a stable supply of vaccines, and someone willing to pay for vaccines are essential and necessary components of any definition of access - but it’s not sufficient.
Beyond needed vaccines and even beyond vaccination coverage, six questions naturally arise:
- Is the vaccine potent at the time of use?
- Is the vaccine administered safely and in a timely manner, before exposure to disease?
- Are all required doses received?
- Do communities perceive the vaccination service is of good enough quality that they want to return for subsequent doses?
- Do programs reach the entire population, including marginalized groups?
- Are programs affordable and sustainable?
These are all health development challenges and go well beyond access to vaccines.
While a focus primarily on inputs can lead to program distortions inconsistent with a broader health development and systems approach, narrow strategies have lately come under scrutiny. Greater attention is being given to strengthening immunization systems capable of routinely reaching infants and other targeted age groups year in and year out.
Both the Bill & Melinda Gates Foundation with its new routine immunization strategy and Gavi, the Vaccine Alliance with its new business strategy are now supporting the strengthening of routine immunization as an integral part of the larger health system, while seeking improvements in equitable vaccination coverage.
For a dichotomy often described as "hardware" versus "software," I prefer a medical analogy relying on anatomy versus physiology, rather than a business analogy to explain that it’s not enough to have a body consisting of organs such as brain, heart, lungs - or in this case, cold rooms, freezers, refrigerators, cold boxes, vaccine carriers - if bodily systems such as blood, endocrine and nerves - or in this case, fuel, spare parts and data - do not provide the spark to make the body - or in this case, the health system - come alive.
In the immunization field, there is growing recognition that in addition to vaccine accessibility there are serious challenges such as availability of vaccination services; awareness of when and where to get vaccinated; acceptability of vaccination and understanding its benefits; affability of services; agency of women to leave home and seek services; affordability for parents to use services and for the health system to provide them; and accountability of the program to community, government and funding agencies.
Strengthening platforms, enabling environments and accountability
In framing the challenge as vaccine inaccessibility, let’s recognize how such semantic constructs determine our search for appropriate solutions, lest we see the sky no better than the proverbial frog stuck in the well.
Our all-consuming focus on single diseases - with their dominant focus on mass campaigns, disease surveillance and laboratories - has diverted us from direct investment in strengthening routine immunization. The legacy of insufficient investment has resulted in a weakened platform in serious need of overhaul. The needed search for innovative solutions, such as re-imagining cold chains of the future, should be accompanied by rediscovering what’s worked in the past.
While some immunization challenges are amenable to technological solutions, much of the so-called low-hanging fruit has already been picked. Consequently, some of the most exciting and innovative solutions - outside our comfort zone - seek to influence the enabling environment itself. One example is the modification of banking procedures in Nigeria’s Kano and Bauchi States, so that recurrent expenses and salaries are disbursed more directly, reliably, and with greater transparency and timeliness.
Whether it's measles elimination or new vaccine introductions, we must rebalance our focus on fortifying the routine immunization platform so it’s capable of delivering timely and quality vaccination at scale each year. Without this, we won’t achieve our more lofty disease control and mortality reduction goals.
In the future, whenever bold initiatives are designed - focused most likely on single diseases, commodities or biologicals - let’s recognize much earlier that the underlying routine immunization platform itself must continuously be strengthened. And donors must hold disease and commodity initiatives of the future more accountable than we’ve held them in the past, so that unintended consequences - so many of which are predictable - are identified from the start, addressed and avoided. What will it take for us to do so?
For now, let’s ensure those sweepers get the support they need to do their job.
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Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.