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Global Immunization Meeting, Kigali, June 2018

Thursday, 28th of June 2018

Notes from the Global Immunization Meeting, Kigali Convention Centre, 26-28 June 2018

DAY ONE

This global meeting brought together some 200 participants from governments, the UN agencies, and partners. The keynote speaker, Helen Rees of Witwatersrand University, spoke on “Navigating Transitions.”

The meeting was opened by Dr. Felicitas Zawaira, WHO/AFRO. After administrative announcements,

The UNICEF rep, Ted Maly, pointed out Rwanda’s achievements in MNtE, GPEI, measles control, and HPV. He noted that we are close to the GPAV deadlines of 2020. How will we adapt in the post-2020 period? How will we move towards Universal Health Care in the context of EPI?

UNICEF reaffirms its commitment to the global immunization agenda.

Diana Changblanc, the acting EPI coordinator, WHO HQ, expressed her gratitude to UNICEF for their support in getting to this day. The previous GIM was in Spain in 2015, with 150 participants; this meeting has attracted 220 participants. The Steering Committee chose “Polio Transition/GAVI Transition/Transition to New Approaches” as the foci of this meeting.  NUVI is the only GVAP indicator, among 6, for which the world is on track to reach the 2020 GVAP goals.

The JRF celebrates its 20^th birthday this year. The JRF, which was 2 ½ pages long in 1998, is today submitted by 190 countries. 

I expect you to leave Kigali with new perspectives on shaping the future of EPI.

Dr. Zuwaira issued three challenges to us: 1) introductions to the people at the same table, 2) attend breakout sessions which are outside your area of specialization, 3) turn off your mobile phones.

We are hoping to hear from new voices.

What are the game changers to increase coverage and equity? How can we increase domestic investment in immunization?

She introduced our keynote speaker, Prof. Helen Rees, University of Witwatersrand, and chair of the RITAG.

Helen chose for her topic “Looking from the Outside In.” Where do vaccines rest within our global world? The good news is that both TFR and U5MR have declined, in synchrony, since the 1950s. Child spacing contributed to achievement of MDG4. Life expectancy has risen in all regions, though AFRO lags the other regions. EPI coverage has increased since the ‘80s, but less quickly in recent years.

The political context affects EPI, notably recent violence in Addis Ababa and Harare. Nationalism has risen in Europe, the US, Russia, and India. Nationalism is the flavor of the day. It is not, however, the best way to go.

Trade wars will affect all of us, especially poor countries. Rejection of migrants in Europe and the US is a retrograde tendency.

What has happened in recent centuries?

• World population has risen.
• Urbanization has taken off.
• Transportation has mushroomed.
• Water use has risen in unsustainable ways.
• Telecommunications has taken off.
• Real GDP has risen, both in OECD and developing countries.
• Income gaps have widened, with most increments going to the wealthiest 1 percent.

Africa is seeing a demographic transition, with an adolescent bulge. But is this a demographic threat if we have no jobs for young people?

The IOM reports that 130 million are migrants of one kind or another. We had >100 conflicts in 2015. The Yemen hosts a proxy war between Saudi Arabia and Iran. Refugee populations are rising, especially Syrians and South Sudanese.

Most displaced persons go into neighboring countries, not into OECD countries. By 2030, half the world’s poor people will live in fragile countries.

Eco-migration will follow in the wake of climate change. Between 2030 and 2050, we will see additional deaths from heat stroke, starvation, and other causes linked to climate change (reference: “Climate Change and Health,” World Bank).

From 1975 onwards, we have seen the emergence of HIV, Ebola, new flu strains, SARS, MERS, and Zika, among others.

WHO has restructured after the Ebola outbreak of 2014, with a new Health Emergencies Programme. We have also mapped the global distribution of pandemic preparedness. The countries least ready to respond are the poorest ones. Disasters affect poor people more than nonpoor people. [graphic]

Urbanization moves apace. It is driven by cities in emerging markets. By 2050, Africa will grow to be 50 percent urban. We are seeing more poorly planned megacities of >10 million people.

Global ambient air pollution is growing, notably in India and China (source: Greenpeace). Deaths from air pollution are commoner in developing than in developed countries.

An estimated 40 percent of under vaccinated children were in urban areas in 2016. Kampala has 3 million people by day and 1 million by night.

Global health funding is at risk during polio transition and GAVI graduation. Polio funding will decline once global eradication is certified, about 2021. Funding for GPEI supports broader vaccination.

DAC funding for health has leveled off in recent years, especially since 2010. Since 2013, there has been an absolute drop. NCDs get little funding. HIV funding rose, then fell. Talk of the “AIDS free generation” has led to complacency.

Modeling has been done on possible impacts of continuing declines in HIV funding. Let’s not take our foot off the pedal.

UHC, universal health coverage, is within reach. [graphic on per capital health spending by country]. SA spends a lot on health, but 80 percent of our spending is on the 16 percent of the population who get services in the private sector. In poor countries, half of all health expenditures are paid out of pocket. This is not the case in richer countries.

Reference: WHO, “Tracking Universal Health Coverage: 2017 Global Monitoring Report.”

Premature lives lost are higher in developing countries, or in those which fail to regulate tobacco.

LMIC countries see NCDs as a major cause of death. This is even more pronounced in UMIC and wealthy countries.

Key reference: Report of the WHO Independent High Level Commission on NCDS, The Lancet, 2018

Dementia and suicide are leading causes of death in OECD countries. Oncology drugs are getting more and more costly. However, additional clinical benefit declines with additional expenditure.

Antimicrobial resistance is a growing threat in all countries.

Gender violence drives HIV, and also drives child neglect.

“The Global Health 50/50 Report,” 2018.

Take home lessons for immunization:

• Donor funding priorities are changing.
• Beware complacency, that immunization job is done.
• Continue to explore new funding modes.
• Domestic financing is essential for sustainability.
• National ownership and political will, smart taxation
• Accountability at all levels
• Engaging civil society is essential.
• Continue dialogue with manufacturers/private sector to keep vaccine prices and services affordable.
• Integration of services is essential.
• New GVAP after 2020

“No man is an island, entire of itself.”

“The times, they are a changing.”

 

Dr Zuwaira: Governance matters. We are missing children, especially girls.

HE the Health Minister of Rwanda opened the meeting. The GoR welcomes you all. Political commitment is essential; we have reaffirmed our political commitment at successive AU summit meetings, and at Davos in 2013.

We have introduced six new vaccines while maintaining high routine coverage. We validated MNTE in 2004, with no WPV since 1993. We have introduced rotavirus, pneumo and HPV, using both fixed and outreach sites. We use GAVI HSS support to address bottlenecks. We distribute transfusion blood by drone, and expect to expand the use of drones.

We expect UHC to be recognized as a human right.

COFFEE BREAK

The next presentation was on global shifts affecting the future of immunization, with a panel discussion by the agencies.

We have seen a decline in VPDs, with burden spread across LICs and MICs. There are growing risks to global health security, with access to health services a major issue. We are working in silos, with loss of the synergies associated with integration. The biggest changes have been in Internet technology and in health technology. Mobile phone usage has mushroomed in all countries. Many phones are smart, with Internet access. There has been a rise in innovative technologies for health, with a universal flu vaccine under development.

Panelists: Aurelia Nguyen, Greg Widmyer, Craig Burgess, Diana Changblanc, and Robin Nandy.

Challenges: reaching every child, increasing domestic funding, addressing equity, vaccine supply, government accountability, and polio eradication.

Opportunities; GPEI, strong partners with commitment, technology, UHC, new vaccines, civil society, life course approaches.

Each table was asked: What is the number one thing we need to change in the way we work, based on the changes in the world in which we operate? Why is this the number one thing?

• Table 25, my table, called for integration at the community level.
• Table 13 called for changes in leadership, with more effective leaders and increases in equity and domestic financing as a result.
• Table 16 called for more government ownership, including funds allocation for health and EPI, with more accountability. Donors should respond to governments’ expressed needs.
• Table 9 called for better governance and accountability at all levels, with conflict resolution.
• Table 2 called for more domestic financing, with a roadmap to financial sustainability. Communities should demand vaccination as a right.   A cross sectoral approach with education is needed, e.g., for HPV.  We need good communication for vaccine hesitancy. Tech assistance should be country driven, done in such a way as to build up country capacity.
• Table 26 called to break the silos.
• Another table called for trust, especially trust among partners and trust between donors and governments, trust between governments and the public at all levels.
• Another table called for joint interagency missions, including civil society. No parachuting.
• Another table called for engaging partners and taking a multisectoral approach, with finance and other sectors involved. In Syria, immunization is defined as a red line. Programme flexibility in light of changing conditions in Syria. We need a change in our mind sets. Cultural can be an enabler for demand creation.
• Another table said that the government has to take charge in the face of donor pressure.  Register uptake by individual children, while tackling inequities within cities.
• Table 14 called for empowering countries to have ownership. This means building capacity. GVAP goals need to be country goals, with household buy-in on preventive health and on immunization.
• Another table said that GAVI graduating countries faced procurement issues. How does PAHO organize around these issues with its revolving fund?
• Another table called for attention to access and better equity. Conflict areas are an important issue. We also talked about the immunization platform as a base for adding other interventions.
• Another table called for integration as a tool of innovation, especially NUVI. Can we bring WES in to complement e.g. rotavirus vaccination?  How do we introduce integration without compromising the quality of the individual components?
• Another table looked at conflict countries, where immunization continues to function. How can EPI serve as the point of entry with its advantages (supply chain, etc.) to bring in other PHC interventions? How can EPI reporting serve to build up HMIS? Our cold chain inventory can serve for other, non-EPI services. The birth registration can serve the health facility, with SMS messaging to the family with immunization reminders. This is the entry point for other services, like growth monitoring.

The panel members spoke on how their organizations are evolving in response to the external environment.

Eric Mast, CDC, spoke first. Global health security is becoming our main focus, with growth in capacity to respond to infectious disease threats. Another shift is the rise in innovative technologies for health. Unity of purpose on the part of global health partners will be crucial in achieving global immunization goals. We are working to strengthen RI in countries with a high burden of disease, especially Nigeria, DRC, and Ethiopia, plus four Asian countries.

Our core areas are surveillance, HMIS, immunization policy, demand for immunization, and immunization financing.

‘We must continue working together to improve immunization delivery and to vaccinate in those hard to reach areas. The last mile is the hardest.” –Redfield, new CDC director

Aurelia Nguyen, GAVI: How does GAVI finish the job in reaching every child?  IDPs are a rising population, and NUVI roll-in is not yet completed. We need specific approaches for IDPs and refugees. How can we support MICs in accelerating their agenda?  How can we support accelerated decision making in graduating countries? How can we contribute to global health security, especially response capacity?

We need to strengthen surveillance and outbreak response.  How do we leverage the GAVI platform for other interventions, both health and non-health? We link other interventions with EPI. We shape markets.

Greg Widmyer, BMGF: We have begun to explore how our different interventions can come together in future.

We work in a volatile, uncertain, complex and ambiguous environment (VUCA world).

We are challenged by a much broader agenda. This shift is good. The greater focus is on SDGs. Immunization is no longer the leading edge of child survival. We are working across sectors on HR, HMIS, and strengthening of financing.

There are tensions in our work between PHC and disease control, between innovation and scaling up, between largest impact and equity focus.

We need an equity based agenda to support gains made, and still reach the pockets of equity.

We are having an impact in disease control. But we are pivoting towards more ambitious targets. On this, we don’t have super clear views.

What kinds of innovations are we aiming for?  We’re like the stock market: past results are no guarantee of future performance. Future context will require change. How will we work differently?

Craig Burgess, representing the GAVI CSO constituency: Our CSO constituency includes 4000 CSOs. There is one constant: people. We feel that active people live in active communities. Do we know these communities? Are they being engaged? What about communities that are left behind?

We have inequities in fragile, transition and rural/urban poor; we need to demonstrate CSO evidence and coordination. Partnerships imply private sector opportunities. CSOs can broker peace in conflict areas.

We also address the issue of antivaccination movements, which is suitable for CSO attention.

We bring in WASH, education and other sectors.

What’s the added value of CSOs? Accountability to communities through civil society voices.

People centered approaches:

• Integrated, appropriate and acceptable services
• Self-organized coordination for what communities need
• Contributing to broader SDG targets
• Bring UHC, GF, GAVI, GFATM, PMNCH CSOs together.

CSO partnerships strengthen trust between people and providers, so that services are more acceptable, appropriate, accountable, integrated, and sustainable.

Diana Changblanc, WHO, spoke next. There are 7.4 billion people on the planet, growing at the rate of 1.09 percent per year. We need to reach 130 m newborns every year. People migrate. They confront unimaginable crises. Services have to follow them. We need to right the inequities. Otherwise, we risk a resurgence of diphtheria, measles and polio, among others. We need a comprehensive surveillance system which anticipates and guides us in response.

With GPEI close, what will the world look like? How will RI focus energies?

Robin Nandy, UNICEF HQ, spoke next. We need to shift our mindset. All the shifts are important. Can we make the shifts in our mind?  EPI is key for revitalizing PHC for UHC, with linkages among services, community partnerships and intersectionality. We might need to shift from the focus on individual diseases. Are we alienating ourselves from the broader public health community? We talk to ourselves about the importance of vaccination. Have we been successful in broadening the public health community?

Whom do we engage with as we reach outside the health sector? We need to position EPI as a key component, the closest thing to a magic bullet.

• UNICEF will use immunization as the tracer for child equity.
• UNICEF will adopt its MO to contribute to health systems.
• UNICEF will strengthen its emphasis is on vaccination for moms and adolescents.
• UNICE will strengthen integrated delivery and supply chain systems.
• UNICEF will strengthen the immunization frontline workforce.
• UNICEF will increase emphasis on building national capacity for social and behavioral change communication.
• UNICEF will continue to work on existing priories, e.g., vaccine supply, financing, outbreak response, and emergency immunization.

Complacency is a problem. We need to maintain our gains and look for ways to exceed our current 87 percent coverage.

Three country participants were asked what they needed to work in this new world.

Afghanistan:  We need to slow down the speed of the GPEI transition. We risk losing the gains seen in the last 20 years. The donors are reducing their finance, though we have a funding gap of $200 million.  We have had many measles outbreaks this year, with inadequate resources to combat them. Polio is an opportunity, since GPEI provides resources for RI.

Barbados: The Caribbean has four areas of priority, 1) climate change, especially recent hurricanes, with inclusion of hep A for relief workers; 2) health systems strengthening; integration is the delivery vehicle for EPI in the Caribbean. We use electronic health records; 3) outbreaks and outbreak response; we are watching the yellow fever situation in other countries, and Zika everywhere 4) the antivaccination movements, as VPDs decline and the social media are increasing.

Uganda:   Our focus is NUVI, with rotavirus roll-in, our fourth NUVI in four years. We get an introduction grant. We need to generate local data both to support NUVI and to monitor impact through better surveillance.

The environment for vaccine delivery is HR. We need trained HWs, such as nurses or midwives. We need to look at that area. How can we assure that the new vaccines are appropriately delivered? We have cold chain issues, both equipment and cold chain management. Finally, we will be graduating from GAVI, and we face sustainability issues.

LUNCH

Breakout Session: Polio Transition, chaired by Helena O’Malley, WHO/AFRO

Diana Changblanc, acting head of EPI, opened the session. GPEI said that we are at 11 WPV in 2018 YTD, an historic low. RI has been heavily cross-subsidized by GPEI. Let’s shift the paradigm. RI plays a role in UHC, and an indicator whether other PHC services are reaching people. The MDGs focused on public health; the SDGs have a broader scope. How do we manage this strategic shift? We have used OPV SIAs to keep population immunity high. We aren’t going to do that anymore. We’re shifting to RI, and will also shift from AFP surveillance to a broader surveillance, viewed holistically. How are we going to work synergistically? GPEI has had benefits for measles lab and surveillance. It’s not realistic to believe that a single disease can absorb GPEI funds. The VDPV outbreaks, most recently in PNG, are a wakeup call. These are some of the thoughts. How are we going to meet the challenge of the health SDGs?

The panel members: Dr Oaten, NPHCDA, Nigeria “Leveraging ADI to strengthen immunization in Nigeria.”

Abuja Declaration: 15 percent of country budget should be allocated to the health sector.

ADI: Nigeria is committed to this.

• Nigeria endorsed the 2016 National Immunization Cluster Survey finding that only 33 percent of children received Penta 3.
• We have prioritized 18 underperforming states to improve RI. We adopted a ten-year strategy for immunization and PHC strengthening (NSIPSS). In 2018, there was a 1 percent increment in the PHC allocation. Government made a collective decision to contribute counterpart funding for the just concluded Nigeria Measles Vaccination Campaign.
• The president flagged off, last year, the “revitalization of PHC for UHC.” One functioning PHC unit per ward of 10 thousand people.
• The country will invest close to USD3 billion to finance its vaccines over the next decade.
• Optimized integrated routine immunization sessions (OIRIS)
• SMS reporting of real time reporting of immunization information by HWs and DQS in states to improve data quality
• Reaching inaccessible communities and reaching every settlement in security threatened areas in collaboration with military and civilian joint task force
• Polio infrastructure being used effectively
• Smart phones being used for data transmission

The measles SIA used polio infrastructure.

Dr U Agarwal, India, noted that their GPEI started in 1995. We started case based polio surveillance. Our last WPV case was in 2011. We introduced measles/rubella surveillance in 2005, using 40,000 polio reporting units. We have introduced NUVI, and improved support to RI.

Heather Scobie: We have case based surveillance for polio, measles, and tetanus. We also have sentinel surveillance for some diseases. We have outbreak- or event-based surveillance.  We have notifiable disease surveillance, without lab confirmation, which is not so useful as other sources.

We have fragmented or parallel surveillance systems. There is weak lab capacity for bacterial diseases.

What is comprehensive VDP surveillance?  It covers more diseases following minimal recommended standards. An essential tool for decision making.

Build-up of surveillance means better governance, infrastructure, coordination, workforce capacity, logistics/communication, monitoring and evaluation, and supportive supervision.

July 2018 will see publication of standards for VPD surveillance.

New diseases to be covered in the surveillance standards: NNT, mumps, rotavirus, typhoid, varicella

Comprehensive surveillance will vary from country to country.

Panel:

Helen Rees said that some countries are already financing surveillance. We need to find out which countries do and do not finance surveillance.

The Pakistani panel member said that their country has had only two WPV cases this year. Accountability is one feature of our polio program. There were huge resources set aside for GPEI, and huge cadres of health workers, even in conflict areas, with good data generated on kids both reached and unreached.

Polio and EPI are not mutually exclusive. We have not successfully created demand for OPV. Parents have not come demanding OPV. The transition discussion is not premature. GPEI will be integrated into the system.

CSOs are not good at generating data, but are excellent in getting a qualitative idea of what the community is discussing. We have concentrations of the urban poor; for these, our development indicators are low. We do not expect high local generation of revenue.

The BMGF member, Greg, said that our first task is to finish the job of polio eradication, regardless of whether we work in RI or in GPEI. The message for us in the immunization community is 1) to recognize that the 16 priority countries have a high capacity for integration into RI 2) partner funding towards government systems needs channeling into health systems, rather than vertical programs 3) counting kids is one accomplishment of GPEI. Measuring progress in this way should continue.

The accountability frameworks of GPEI are strong in most countries. Can this framework work for EPI?  GPEI has created political will in some geographies. Can this be used for EPI as well as GPEI?

A caveat on the donor front: BMGF is committed. We are having an internal discussion on surveillance. Let’s be realistic about other funding that goes into the program. Will all bilaterals behave as they have behaved in the past?

The USAID CSO rep said that we have new chances to interact with civil society. Civil society is heterogeneous, containing, for example, professional societies as well as community based ones.

CSOs can engage parliamentarians to increase domestic funding. CSOs can assist in reaching slums. These are great roles, post-2020.  The CORE Group has secured the trust of the community.

How can we better engage with civil society? We need them in the room. We need a coordinated approach. CSO can look at smart ways to generate domestic financing.

The GAVI rep, Pascal, tried to dispel the notion of vertical and integrated funding. Using disease specific money for entry points is supportive of integrated approaches, as seen in our host country, Rwanda. Mutual trust is the enabling environment for flexibility towards HSS, as distinguished from project specific approaches. You need a strong plan, with buy-in of all stakeholders, including the government. Nigeria is starting to turn around, with a shift towards building trust between GAVI and the government. Finally, you need management capacity at the national and subnational levels to implement what has been agreed on. This is an area in which we have had underinvestment.

Countries have a huge role to play at the global level. Their voices on boards of global bodies are important. We count on them to orient how we conduct our business. How can we strengthen those voices?

From GAVI’s perspective, the polio transition was seen initially as a risk, but is now seen more as an opportunity.

During the discussion, Katrina Kretsinger noted VPD surveillance remains a concern. Davis noted the recent VDPV findings from Papua New Guinea. In addition, AFP surveillance, in decline in Kenya, did not catch the polio transmission recently detected by ES. Are we ratcheting down our AFP surveillance budgets too quickly?

Robin Biellik noted a Bangladesh experience in polio transition. In the transition thinking, the government had entirely integrated surveillance functions into the MoH, but the medical surveillance officers had not been transitioned to government posts. We hit an obstacle. Governments are to take ownership, but we failed in this. The MSOs are not being absorbed into the government payroll. We’ve seen examples where governments are not ready to absorb their financial responsibilities.

Dr N. Yussuf, UNICEF/ESARO, was happy to learn about the progress being made in Nigeria. Do you have strategies to sustain all these initiatives, in light of the changes at presidential and state levels?

One participant from DRC noted their VDPV cases from 2017. For surveillance, we need a lot in DRC. We have developed a transition plan, but funding for surveillance is absent. When the polio ramp down came last year, with 35 posts abolished, the AFP surveillance began to decline. Now, we have no money. GAVI helped with 11 staffers in remote areas.

An Indian MO, from Uttar Pradesh, wanted to know how they have optimized their national schedule. How does Pakistan assure access to remote areas?

The chair asked for responses from panel members.

Nigerian panelist: We have military checkpoints for surveillance. We have a national health act, which lays down our policies. We use polio infrastructure. Most health facilities in the 18 states have compulsory integration of vaccination services. Heather Scobie said that there are minimum standards set down by WHO for each disease, including, for some diseases, case based surveillance.

Helen Rees agreed that governments have to think creatively to develop resources, largely through investment cases. This is a good case to make.

Bangladeshi panelist: We don’t interference in any CSO affairs. We are non-political and non-religious.

USAID CSO panelist: Civil society can use communication as a tool. They can, for example, use scorecards. These skill sets do exist, and they can generate evidence. 

The GAVI panelist said that the transition plans have not been so sharp and focused as they have been. We may need an investment case.

LSHTM participant: Do we think that all GPEI efforts have created demand for polio vaccine? Is there insufficient ownership?  I worry about surveillance. Can we separate surveillance from clinical care? Governments need to strengthen labs as part of their routine clinical care.

UNICEF participant: I don’t think we can make a strong investment case for AFP surveillance. What are the minimum standards for surveillance, including AFP surveillance? Let’s forget about asset mapping and get down to cases.

UNF: Agreed that with minimum standards, we are on the right track. But we need to cost these items and find out what’s funded and what’s not funded.

Pauline Harvey, WHO/India: Congratulations to the organizers. No one posed the question to India. India has had the most complex context for transitioning. Each of the 36 states has health as a state function. India went from GPEI funding to the point where domestic resources are partially funding the transition. The technical partnership is priceless. We will continue to do VPD surveillance, forever. There are many lessons to be learned from India, even if domestic funding is not yet optimal.

Heather Scobie, CDC: We support lab for public health, not for clinical diagnostics. If you decentralize, you need to assure adherence to the WHO standards. We’re not there yet.

COFFEE BREAK

A world of innovation: What immunization can learn from other sectors

Chung-won Lee, CDC, chaired the session, with Johannes Ahrendts, GAVI. She reminded us of the large number of unimmunized kids, especially in large African and South Asian countries.

There were four exemplary challenges:

1. 1.       Weak governance and accountability, winning 44 percent among those present for the presentation
2. 2.       Challenges in service delivery, winning 19 percent
3. 3.       Gaps in workforce capabilities, winning 15 percent
4. 4.       Insufficient demand generation, winning 27 percent

Johannes said that from 100 potential case studies, they chose 12 case studies.

Question: What if we could build strong mechanisms for national managers?

On governance, we looked briefly at studies by 9 organizations. We chose, from these, three case studies: malaria governance, WFP, and the Tony Blair Initiative for Governance.

ALMA is an alliance of 49 heads of state for a collective response to the malaria challenge. It uses a scorecard to track bottlenecks in fighting malaria [example of scorecard]. It includes input, process and outcome indicators.

The score card allows real-time visibility over key indicators. Countries sit together and discuss results. Discussions provide clarity around next steps/actions. Heads of state leadership facilitates action being taken on agreed actions. The clear assignment of responsibility focuses responsibility.

The owners of ALMA are impressed, by example, on malaria monotherapy. Countries with monotherapy ban increased by 29 percent between 2011 and 2014.

The next example is from WFP: system for cash operations, piloted in el Salvador, South Sudan and Uganda with rollout planned in ten countries in 2018. Digitized community management of malnourished children. Improved real time management: field managers can assess program performance in real time and optimize it accordingly. In South Sudan, they achieved USD100,000 savings derived by reducing inclusion error from 21 percent to 1 percent. There was a 38 percent participation increase, facilitating follow-up with kids who miss treatments.

The Tony Blair Institute for Global Change embeds teams for two years within governments, helping them to define priorities and trigger accountability. Done at the national level in 8 countries in East and West Africa.

Embedded staffers were used to define priorities and trigger accountability plans.

Work of embedded teams:

• Focus on highest levels of political leadership
• Not direct involvement in politics
• Help to identify priorities, support identification of bottlenecks and trigger action
• Aim for sustainability by capacitating governments throughout the partnership

Focus is on central decision making, not the subnational level.

Benefited from Blair’s personal relationships and influence

Operational challenges: going to scale.

More than 3/5 of those present for this session found the ALMA model most interesting.

The ALMA model is interesting for ADI.

Jules Millogo, Merck: All these models predicate interest on the part of players.

JSI: Two things stand out from ALMA: the use of the scorecard, and the peer mechanism among heads of state.

Alain Poy, AFRO: The dashboard is interesting. For EPI, should we look at coverage, or something else?

Chair: Should we add EPI indicators to the malaria scorecard, or do a separate scorecard for EPI?

Millogo: You need to understand the manager’s working environment. Having an external body may or may not be helpful. These are political decisions.

One participant: the key word is “realistic.” Sometimes, targets are set externally. Figures are over-inflated.

RITAG member: Other than showing the results to heads of state, are there any other carrots or sticks?

Johannes: No. The main incentive is peer pressure.

Diana Changblanc: Non-financial incentives are chosen. The key question is, who’s around the table when the scorecard is disclosed?

Davis: The ALMA scorecard could easily become the model for an ADI scorecard, based on WHO/UNICEF estimates and JRF data. This could be piggybacked onto the ALMA model.

Johannes then discussed demand generation, with a 7 percent dropout rate for DPT1.

What if we used new marketing methods to reach more families?

We are focusing on three different marketing methods.

• Behavioral modeling
• Customer insight based marketing
• Social listening

ETHIOPIA, Family Planning

Behavioral modeling was used with radio drama in Ethiopia to encourage contraceptive use and HIV testing.

They started with ethnographic research to look at FP attitudes. They plugged messages into 250 episodes of two radio series. The total fertility rate declined from 5.4 to 4.3, and they had three times higher HIV testing rates among listeners as among non-listeners. There was a 160 percent increase in demand for contraceptives.

There were more than 35,000 letters from listeners to the radio shows.

INDIA, TOILET USE

Second case study: toilet use in India, with men as the target audience and young boys as the messengers.

The ad series won the prize from the Bombay Ad Club.

BRAZIL, ZIKA OUTBREAK EDUCATION

UNICEF and Facebook used Facebook insights to create effective public information.

Since most users are men, they post about a father and his child born with microcephaly.

• Engagement with UNICEF/ Brazil campaigns: from 3 to 8 percent
• Awareness of UNICEF efforts around Zika: from 29 to 36 percent
• Do you plan to protect yourself? From 79 to 82 percent.

Among those voting, the Ethiopian radio campaign was most favored, but the percentages were close.

 

DAY TWO

Breakfast

There was an animated discussion over breakfast today on the TT to Td transition, with UNICEF SD, following the PAHO lead, cutting off TT provision from 2020. Only self-procuring countries will be able to get TT with effect from 2020.

Three points came up, among others.

1. 1.       Can tetanus vaccine be part of the 2YL platform? Not Td, unless used off label.
2. 2.       Why is Td so rarely given along with HPV in school health activities?
3. 3.       Should Td boosters be given routinely pre-circumcision to adolescents and adults undergoing circumcision, either traditional or modern?

PLENARY SESSION

The first session was chaired by Robin Nandy, UNICEF HQ.

Immunization coverage and equity was the topic of the first session.

The presenter, Ola Rosling, presented on Gapminder “fighting devastating ignorance with a fact based worldview that everyone can understand.”

Three mega-misconceptions:

1. 1.       The world is divided into developed and developing countries.
2. 2.       The world is getting worse.
3. 3.       The world population just increases.

Gapminder is a non-profit which looks for ignorance and finds it.  On global warming, Swedes gave the correct answer in 82 percent of all cases. All countries surveyed scored at least 76 percent. Among GIM respondents, 99 percent scored correctly.

In the last 20 years, those living in extreme poverty have almost halved. Most countries scored 25 percent or less. In the US, only 5 percent scored correctly. GIM respondents responded correctly in 56 percent of all cases. Among the other 44 percent, 29 percent said “poverty doubled.”

What is world life expectancy? 50, 60 or 70 years?  [scatter graph showing country level data]

The correct answer is 70 years, which correlates with GDP per capita. But Lebanon and SA, with the same GDP, have a gap, 63 years in SA and 80 in the Lebanon.

The longest era of war-free world, from 1945 onwards, shows increasing life expectancy. CAR and Lesotho, at the bottom, have higher life expectancies today than the Europe of 1800.

In 1800, we were at 31 years. Today, we are at 72 years.

Only 36 percent of the GIM respondents correctly answered 70 years.

How many years have women of 30 years of age in school? The correct answer is 9. In most countries, girls are overtaking boys in school enrolment.

“Factfulness,” his co-authored book, looks at the domain of facts.

GIM participants gave the right answer in 10 percent of all cases.

How many of the world’s kids have been vaccinated against some disease? The correct answer is 80 percent or higher. The figure for 2016 was 88 percent.

In Sweden, 21 percent of respondents gave the right answer. All other countries scored even lower. The experts at the World Health Summit in Berlin gave the correct answer only 27 percent of the time. The GIM respondents gave the correct answer in 73 percent of all cases.

In most surveys, over half of respondents said that coverage was 20 percent. At Davos, 62 percent.

Among US journalists, 20 percent gave the right answer. The majority conveys the dystopic worldview shared by themselves and their readers. Swedish journalists do no better than US journalists.

How can we solve this problem? We are influenced by the images we see on TV.

The GIM respondents averaged 4.1 correct answers out of 12, slightly better than chimpanzees.

Most Swedish students believe that they are at the 50^th percentile in world wealth. In fact, they are in the top 15 percent.

1)      The world is not divided in two. There are four levels of income, there are 1 billion in the very poor, and 1 billion in the very rich. The remaining five million are either LMIC or UMIC.

2)      The world is getting better; in fact, 32 things are improving. Leaded gasoline, child deaths, and deaths from violence are all going down. Protected nature is going up.

3)      The world population is not JUST increasing. There is an assumption that child survival means galloping demography. Of our 7 billion population, 4 billion live in Asia, with 1 billion each in Africa, Europe and the Americas. Most people put 2 billion in Africa, which has only 1 billion.

By 2100, there will be 5 billion Asians, 4 billion Africans, and 1 billion in the Americas and Europe. Thus, the West will be 8 percent of the world’s population, counting N America and Europe.

TFR fell from 6 per woman in 1800. Today, the TFR is about 2.5.

How many children will there be in 2100 according to the UN? 2 billion is the correct answer. In no country do half the respondents give the right answer. In the US, 10 percent give the right answer.

The UN expects more adults, but a stable number of children.

There will be 8 billion persons by 2030. By 2060, we will be 10 billion.

The TFR has dropped like a stone; only the adult population is on the increase.

Solutions to the general ignorance?

Our perception of the world goes through a filter. We get opinions.

Ten solutions:

1)      “Huge gap?” No, locate the majority.

2)      “Everything’s worse.” “No plane crashes today.”

3)      Straight line extrapolation.  Car accidents go up, then down. Lines are not straight. They bend.

4)      Fear. “Help!”

5)      Size: it’s a huge problem. Or is it?  In 1950, we had 14 m infant deaths. In 2016, the figure was 4.4 m.

6)      Generalization: “They are all the same!”

7)      Destiny: It will always be like this, notably culture.

8)      Single solution: The hammer is good for nails and not for screws. We need a toolbox, not tools.

9)      Blame: “It was him!” Is there another explanation?

10)  Action: “Now or never!” Let’s take the final decision, rather than one step at a time.

Let’s put warning labels on tabloids: “The newspapers often make things seem very alarming.”

Gapminder.org has a web link to the tests, with certificates for those who get 100 percent.

We give out certificates in Swedish high schools.

Key ref: H Larson et al., “Measuring Trust in Vaccination: A Systematic Review.”

https://www.tandfonline.com/doi/full/10.1080/21645515.2018.1459252

In France, 40 percent believe that shots are not safe.  But 97 percent are vaccinated. The correlation is not there. In the Ukraine, there is a correlation. In Russia, high distrust correlates with high coverage, puzzlingly.

www.prio.no shows numbers of kids and adults living within 50 km of a conflict area.

DHS data now show coverage by quintile, with lower coverage correlated to lower incomes.

In Nigeria, the lowest quintile has 10 percent EPI coverage. National averages are misleading.

TFR is a function of income. The poor have more. Once you get past $2 per day per person, fertility declines, and vaccination coverage increases.

 

Our chair, Robin Nandy, congratulated the presenters for better understanding the world in which we work. Perceptions and reality are two different things. Gapminder is our friend. He distributed free copies of “Factfulness,” a book co-authored by the deceased Hans Rosling.

COFFEE BREAK

 

BREAKOUT SESSIONS

A Framework for Changing Behavior, Nathan Pienkowski, nathan@bulcitylearning.com

Among neophytes in forklift operations, those who read the manual were less adept than those who skipped the manual and practiced on the forklift.

In our EPI training, we leave a lot of people stranded on the wrong side of this gap between knowing and doing. It is the task of workforce development to close the gap. Otherwise, we give them classroom training, without building a bridge across the chasm between knowing and doing.

The US spends $161 b on organizational workforce development. Much of this money is misspent. 

We stay in the same rut even as the pace of change accelerates, wherever we look.

How can we cross the chasm? The building blocks are there, based on Teach 2 Reach:

• Job aids
• Engaging learners
• Performance management
• Just in time learning
• Personalized learning
• Adaptive learning
• Case based learning
• Smile sheets

We reject training and learning in favor of behavior. Training and learning are mere intermediate steps, and mean little unless they change behavior.

Classroom teaching can have a negative impact, closing off options for development.

We need both stimulus and response, but with the emphasis on response. An airline CEO ordered red wine, which was served in a white wine glass. He ordered retraining, but still got red wine in a white wine glass. Why? Because his airline only stocked white wine glasses. So the retraining was wasted.

Your first reaction to a problem is diagnosis of the performance deficiency. Do not seek a training solution for a non-training problem.

Will an overworked, undertrained nurse complete the revised forms package correctly? Never.

Will the drug detailer mention off label uses if told not to do so? Yes, if it will improve sales.

We need solutions which address the brain and, as well, the body (the physical environment in which people work). Brain, body, backdrop. Reward mechanisms influence behavior. A holistic approach addresses everything.

 

 

 

 

 

 

 

Whole person learning canvas:

System outcome		Behavior
Brain component	Body component		Backdrop component

 

This template can be used for doing a sitrep, for doing a needs analysis, for reviewing resources currently available. How does supervision work, and how is performance evaluated?

This template can also document strategy.

 

Missed Opportunities for Vaccination, Blanche Philomene-Anya, WHO/AFRO

Any contact with the health system which does not result in vaccination is a missed opportunity.

Problems:

• Vaccine stock outs
• Failure to check vaccination status
• Failure to check sibling for vaccination status
• Failure to check mother for tetanus vaccination status

Main components of the MOV strategy:

1)      Planning guide

2)      Methodology

3)      Intervention guidebook

The first step Is the assessment, using electronic data collection.  You conduct the interview with mother and photograph the card. Then, focus group discussions, then designing interventions to take corrective measures.

Where the 2YL approach has been adopted, the plan should include measures to assure implementation of 2YL, especially MCV2.

In Kenya, 30 percent of 55 kids had a missed opportunity. The figure was 90 percent in Sokoto.

Typically, the MOV was associated with medical consultation. Sometimes, a sibling goes unvaccinated because they are there only to accompany the mother.

Summary of reasons:

Clinic side:

• Limited hours
• Stockouts
• Poorly designed records
• Vaccination card availability

Maternal side:

• Vaccine hesitancy
• Lack of knowledge of schedules
• No card

Interventions:

1. 1.       Update policy with community engagement and fresh EPI manuals
2. 2.       Service delivery, with screening desks in health facilities
3. 3.       Health workers: training of health workers
4. 4.       DRC presentation, Guillaume (EPI director)

Nine activities to reduce MOV:

1)      Train staff member on routine EPI

2)      Provide continuing training through formative supervision

3)      Promote national EPI guidelines

4)      Support guidelines implementation

5)      Intensify communication with parents

6)      Provide solar fridges

7)      Transport vaccines to all health areas

8)      Ensure free health cards

9)      Ensure motivation of providers (financial or non-financial)

We use tokens (jetons) for each child.

In Kinshasa West, we have seen increases in DPT3 associated with MOV implementation.

Ref: “Les OMV dans une zone de sante urbaine,” based on experience in Ndjili.

 

LUNCH

Urban Routine Immunization, co-hosted by BMGF and UNICEF.

The session will start with a UNICEF (Godwin Mindra) overview of urban immunization, followed by a presentation by Richard Mihigo, WHO/AFRO.

Both Asia and Africa have rapid urban population growth, with growing slum populations. One in three urbanites is a slum dweller, creating cities within cities. Kenya is now > 30 percent urban.  The drivers of urbanization are natural growth, conflict, and migration.

Risks:

• Disease transmission and outbreaks
• Underestimation/overestimation of programme needs
• Missing out the recent arrivals, especially <12 months
• Missed opportunities from collaboration and partnership, including with the private sector

Undervaccinated kids are in conflict areas, rural areas, and in urban areas, especially slums.

Typically, urban coverage is higher than rural, but sub-analysis of the urban data shows that slums are under-vaccinated. Quintile analysis shows the real state of things, as well documented in DRC, Ethiopia, and Nigeria.

Are current programme delivery platforms addressing the challenge?

• Complex governance and political will
• Densely populated neighborhoods
• Mobile populations
• Weak data systems
• Weak social fabric
• Multiple stakeholders
• Multiplicity of communication channels
• Disenfranchised communities

Mihigo spoke next. He introduced a panel of five discussants. Florence Kabuga, MoH/Kenya, said that the daytime population of greater Nairobi is 6 million, with 4.6 million at night.

Mathare slum has performed below 55 percent coverage. What are the barriers?

Different data sources are used: DHIS, landscape assessment, coverage surveys, REC facility microplanning

[graphics showing coverage under 60 percent, with disparities within Mathare.]

Findings:

• About 70 to 80 percent of kids were vaccinated. There are access and utilization issues. There are wards without EPI facilities. There is constant population movement.
• Services are unknown by the community.
• There is a cost in private facilities.
• There is insecurity.
• Long waiting times
• Clinical times not convenient
• Data quality

Ngozi Kennedy, UNICEF/Liberia, spoke on Monrovia. She is currently team lead for EPI.

EPI review, 2012, identified urban vaccination as a unique challenge.

Many urban poor kids are not reached by EPI.

DHS showed disparities by quintiles.

Most poor children are found in urban slums in Montserrado County, which hosts 33 percent of the <1 target for immunization.

In Montserrado, 80 percent of facilities are private for profit.

Actions taken:

1)      Increase service delivery platforms, with support by geomapping and vaccination points in 15 large markets

2)      Advocacy and community engagement, with community meetings and follow-up meetings in communities and places of worship; advocacy meetings held in large market sites with head of marketing associations; training of CHVs on immunization, with focus on defaulter tracing; provision of phone to health facilities to make reminder calls to defaulters

We saw dropout rates decline from 22 to 15 percent, BCG to measles, post-intervention.

Lessons learned:

• Partnership with private HFs contributes to coverage improvement.
• Presence of vaccinators in markets enabled busy moms to access EPI.
• Provision of phones has increased the numbers of defaulters tracked.
• There is still a need to explore other platforms.

Dr Pradeep Haldar, MoHFW, GoI, spoke next.

We have 1057 cities with populations over 50,000. Focus on slums, building sites and marginalized populations

• ANMs identified for every 10,000 population to provide outreach
• Mapping of areas under each ANM
• Provision for hiring alternate vaccinators in case of HR shortage
• ASHA identified for each slum to mobilize beneficiaries for immunization services.
• Urban task force on immunization being formed in these areas
• Strong coordinate with Ministry of Women and Child development through anganwadi workers
• Special immunization drives to cover dropouts identified through head count survey
• Support of youth organization and other line ministries taken for social mobilization
• Various innovations in line with local needs: flexible session times, mobilization of vaccinators from rural areas

 

George Bonsu, Ghana EPI manager, spoke next.

Ten percent of kids don’t get DPT3 or MCV1.

17 percent of kids don’t get MCV2.

Most of these kids are in slums.

Largest numbers of unimmunized are in Accra and Kumasi. This is especially the case for MR2.

We worked with JSI to address the challenge.

Urban diagnostics:

• Planning and management of resources
• Human resources for RI
• Availability of RI
• Access to services
• Use of the services

Some preliminary findings:

• Inadequate service points in slums
• Inconvenient times
• Weak involvement of private clinics
• No defaulter tracking
• Weak collaboration with school health services
• Low level of awareness and fear of AEFI

What is being done:

• Mapping of all urban and periurban slums
• Container clinics in markets and slums
• Weekend vaccination sessions
• Generation of monthly defaulter list for follow-up
• Strengthening demand generation: radio jingles, community engagement by NGO coalition
• Screening of schoolchildren for missed vaccines

Conclusions:

• One size does not fit all.
• Different factors affect immunization, so tailor-made approaches are necessary.

JSI (Craig Burgess) spoke on urban issues, especially integration and CSO collaboration.

Integration is the backbone of PHC, most equitable services, same target groups as for MNCH-nutrition.

 

Barriers:

• Timing of sessions
• Payment
• Non-registration of migrants
• Unclear stakeholders
• Denominator issues
• Culture, language and ethnicity
• Communication and advocacy for vulnerable communities

Solutions need to be customized.

Supply chain:

• Reliable electricity
• Assume CHW gets vaccines often
• Target population estimates impact on supply chain
• Drones?
• Better access to electricity.

Mihigo: From these experiences, how do they apply to our respective countries? From what we have heard, are there issues not yet addressed?

Discussion:

Nasir Yusuf: There are security issues in many slums. We don’t have good disaggregated population data. Why do we not go to scale after pilot projects? Do we need to reach out beyond health services? What is the juridical status of the slums? Populations are here today and gone tomorrow. Non-registration of migrants.

Another group: There are urban no man’s land, not recognized by any local authority, often with highly mobile populations. The private network of doctors and quacks is there. Should we tap it? Do they have a better knowledge of the population than we do? Vaccinations should be free, including those provided by private clinics.

Haldar: Migration comes up again and again. We need a strategy for tagging and tracking of migrants; otherwise, we shall continue to miss them.

We have mega-cities in Egypt and India, among other countries. This poses a problem of the denominator. In particular, people live in one place and are vaccinated in another. Is there an IT solution to the counting of these populations?

UNICEF is developing a toolkit on urban health services, with copies in the UNICEF booth.

Katrina Kretsinger chaired the SIA/PIRI session.

Dr Pradeep Haldar presented on India’s MR vaccines, which started in the better organized states of southern India, with variable linkage with the schools. There were inaccurate AEFI reports circulated through the media. This Phase 1 generated many lessons: PM promoting the MR campaign, with committees at central and state levels. There were 12 ministries involved in Phase 2. There were four week campaigns, with schools and communities initially involved, then the final week sweeping in low performing activities.

Phase 2 had improved activities in schools, with Lions’ involvement. Medical colleges were involved in Phase 2, and meetings were held with religious leaders. This prevented negative comments from religious leaders.

Trainings were done at state, district and subdistrict levels; microplannings were done from the subdistrict up.

There was collaboration with private practitioners.

We involved Amitabh Bachchan, the well-known Bollywood actor, as well as Dr Devi Shetty, the famous cardiologist. Media engagement and celebrity endorsements played a role.

We produced FAQ sheets in different languages for different audiences.

In phase 2, children were observed for AEFI for 30 minutes after MR vaccination.

We did successive assessments by districts of operations and communications, with improvements over time.

There were WHO and UNICEF experts deployed.

To date, we have rolled out MR in 20 states/UTs. Average administrative coverage has been 95 percent.

India is committed to achieve ME by 2020.

Robin Biellik spoke about SIAs and RI, “ISS through measles and rubella elimination.”

Measles and rubella elimination requires strategies over and above routine immunization because of the epidemiology of these diseases.

The correct balance between RI and SIAs has been the subject of intense debate for over 50 years. SIAs, properly implemented, do not disrupt RI.

Reference: Fields R et al “Moving forward with strengthening routine immunization delivery as part of measles and rubella elimination activities,” Vaccine, 2013.

The full potential of using MR elimination activities to strengthen RI has not been met, according to MTR of the MR Global Strategic Plan, 2016.

We aimed to document national examples in a report submitted to WHO and MRI.

We sought country examples of SIAs as strengthening RI, the categorized country examples in line with the adapted GRISP recommendations for strengthening RI.

We analyzed examples and drew conclusions on these strategies and activities that showed positive impact and appeared reproducible in multiple settings.

[table showing survey results by country and activity] The activity most often cited from the five listed was strengthening RI by social mob, training, and additional resources like cold chain and transport.

Survey conclusions:

Multiple examples of using MR elimination to strengthen RI were identified, but data on cost, impact and sustainability were not available.

Most frequent activities:

• Extensive advocacy and education on RI
• Extensive HCW refresher training
• Cold chain expansion
• Unvaccinated children identified before, during and after SIAs, but little evidence that these kids were followed up and vaccinated.

No examples seen thus far on the 2YL platform.

Recommendations:

• A protocol should be developed to assess SIA impact on immunization systems.
• Current efforts to strengthen RI through SIAs should be sustained and, where possible, expanded.
• All SIAs offer the chance to check vaccination records.
• Steps to close the immunity gap should be promoted.
• Efforts to introduce 2YL platforms should be accelerated.

This paper, by Biellik and Orenstein, has been submitted to Vaccine.

Three examples of country efforts:

Heather Scobie, “Coverage survey and evaluation of SMS use for the MR campaign in Kenya, 2016.”

The MR campaign targeted 19 million kids <15. The post-SIA survey showed 95 percent coverage, and included evaluation of campaign SMS reminders. The admin coverage was 101 percent.

[campaign results for each of the 47 counties; 20 counties passed the 95 percent threshold, 2 failed, and 25 counties were intermediate.]  There were a six months’ delay, a careful microplanning exercise, interpersonal communication (IPC), mass media, H2H in three counties, and SMS reminders.

The SMS project partnered with Safaricom and Airtel. There were 22 counties targeted, but much contamination across county borders. Nationwide, 29 percent received an SMS.

Because of the 95 percent coverage, it was difficult to tease out the differential impact of the SMS alerts.

Imran Mirza spoke about innovations and lessons learned from the 2017 measles campaign in Indonesia.

“Business as usual” was not an option, especially in light of antivaccination movements and uneven coverage of underserved populations.

UNICEF did a KAP survey on parental attitudes, as well as three polls on Twitter and Facebook, providing insights on public knowledge of the campaign. There were weekly alerts tracking rumors on the social media.

UNICEF also used Rapid Pro through SMS based technology.

Vaccinators submitted daily coverage data via SMS. These data were sent to the RapidPro platform for automated analysis and real time presentation on the dashboard. There was immediate feedback to the field. This system enabled managers quickly to identify and assess problems and take corrective action.

Results: Over 95 percent coverage in all six targeted provinces.

Lessons learned:

• Effective communications increase trust.
• Communications keeps evolving.
• Digital listening has great potential.
• Measles communication approaches are essential to promote routine and the 2YL approach.

Robert Davis presented on Amcross supported SIA activities in Malawi and planned PIRI activities in Kenya. I observed that the NLM database has 235 citations on SIAs, but only 1 (one) on PIRI.

Discussion:

Robin Nandy said that frequent SIAs were disruptive of RI. The essential was, what do we do between successive SIAs to build up the routine? He appreciated that SIAs, properly conducted, could serve to strengthen RI. He noted the great differences between SIAs and PIRI exercises.

A PAHO participant said that post-SIA evaluation had to go down to the lowest admin level, i.e., the municipality. If 95 percent coverage were not achieved in every municipality, virus reintroduction was possible.

Another participant asked if a simple ecological analysis could test the hypothesis that SIAs improve routine coverage (to which Biellik replied that such an analysis, outside his ToR, was feasible).

Balcha noted that, while measles coverage has plateaued, AFRO has seen declines in measles incidence, largely attributable to SIAs. He approved of house to house mobilization, which, he said, needed scaling up. He thought that generalizations drawn from South Sudan, DRC and Nigeria were not justified. The region, as a whole, was down to about 15 cases per 100,000 per year, a steep decline from a decade ago.

Katrina said that there were trade-offs in SIA postponements. They were sometimes necessary when the pace of preparations was slower than expected.

Biellik said that cold chain improvements might or might not improve RI. Some cold chain improvements simply kept up with the need to expand capacity to accommodate new vaccines.

Imran said that SIAs do not harm RI unless the time between successive SIAs is ill spent.

One member of the audience asked if Robin had looked at microplans. Yes, he had. In some countries, maps generated during SIA microplanning were kept to assist in planning for routine.

One person asked about the fate of MCV SIAs in countries like Congo/Brazzaville, which are losing their GAVI funding. This question went unanswered.

Another person asked about economic analyses of measles eradication. I referred her to the work of Kimberly Thompson, most of it accessible at www.kidrisk.org

UNICEF/Yemen pointed to the deficiencies in MCV2 coverage in countries with two dose regimes. What, if anything, had SIAs done to improve MCV2 coverage?

Biellik, responding to several comments, rejected comparisons between polio and measles. Notably, measles does not persist in the environment, does not require multiple successive SIAs within a short period, and is almost never asymptomatic. In all these, it is as different from polio as is cheese from chalk.

Davis praised the phased SIA approach practiced, for example, in Nigeria and Mozambique. The Phase 2 SIAs in southern Mozambique benefited from the lessons learned exercise conducted between Phase 1 and Phase 2 in that country; the Phase 2 southern provinces had significantly higher coverage than the northern provinces done in Phase 1.

Heather Scobie noted that vaccine hesitancy in Kenya, and the bishops’ attacks on the SIAs, had no significant impact on the coverage seen in the 2016 MR SIA.

Katrina concluded the discussions, which ran 15 minutes over, by saying that today’s discussions were part of an ongoing debate. We need more data to inform our discussions.

DAY THREE

Polio Transition Planning

Ebru Ekeman, WHO HQ, chaired a breakfast discussion on polio transition planning. Robin Biellik pointed out that Bangladesh had abolished dozens of GPEI funded SMO positions, imperiling the future of surveillance in that country. I pointed out the example of Angola, where the ramp down of GPEI and the GAVI graduation had left the oil rich country with little domestic funding for the health ministry, so much so that the GAVI Board made special provision for extended post-graduation support so as to prevent the collapse of their EPI.

Since AFRO gets 2/3 of its budget from GPEI, 2021 and later years will, absent a successful call to donors, signal the collapse of the regional office. Deloitte is assisting AFRO in putting together an investment case scenario which will, if fully funded, maintain the AFRO budget at its current level.

Craig Burgess pointed out that civil society should assist in polio transition planning. In most countries, neither civil society nor parliamentarians have been involved in a process which has, generally, involved the governments and the UN agencies.

If there is much for our comfort in these transitional planning exercises, it did not come out at this session.

 

Plenary Session: Resource Mobilization

Diana Changblanc chaired the first session, with Tom O’Connell (WHO), Logan Brenzel (BMGF), and Albamaria Perez (PAHO) as panelists.

Tom O’Connell started with a video on global health financing. The world spends about 10 percent of global GDP on health. That’s $7.3 trillion, growing 4 percent yearly, and 6 percent annually in developing countries.

More than 50 percent of the world’s population has no or limited access to health services.

Logan Brenzel presented on financing immunization programs in an era of transition.

Of $7.3 trillion on health expenditure, only 20 percent is spent in MICs and LICs. Of this, HH expenditure accounts for ½.

For every dollar invested in EPI, at least $16 comes back to the economy. The true figure is closer to $44.

[graph showing JRF data on government EPI expenditure; despite small increments, LICs spend about $10 per child per year on immunization. Vaccine spending accounts for 1-2 percent of total government health spending.

It used to cost $20 fully to immunize a child. Costs vary between and within countries.

Government budgets are the key component of EPI financing. More directed advocacy is needed at this level.  This means engaging provincial authorities and mayors, among others. A strong PHC structure is also necessary.

Devolution in Kenya:

Counties have been responsible for EPI since 2013.  Counties get vaccines from the central government.

Increased community participation: closer to the people; increased accountability; increased funding; improved access

Challenges: no system to track expenditure; few allocations; inconsistent availability of immunization services

The GAVI transition has implications for immunization financing.

Countries need to take responsibly for rising coverage rates, procurement capacity, with peer learning and TA provided by GAVI post-transition.

So far, 16 countries have graduated from GAVI. In Africa, Angola, Congo/Brazzaville. Some countries are struggling with the transition.

All graduating countries are seeing GPEI ramp down. Some are graduating from the GFATM as well.

A few are losing World Bank IDA funding.

Middle income countries face financing and program challenges. External support for EPI is limited. MICs account for 1/3 of globally reported measles cases. They lag on NUVI. Their vaccine price tag is higher.

How to manage transition?

Fiscal space for EPI increased by

• Greater allocation of state budget
• Reallocation of MoH budget to prevention
• Complete execution of EPI budget
• Innovative financing mechanisms
• Asking for more funding from MoF
• Improved efficiency and use of resources

Most MoH spending is for curative, not preventive, services.

Social health insurance is part of UHC, and reduces medical impoverishment though pooling.

Legislation can contribute to political commitment.

Key messages:

Immunization expenditures are increasing, but slowly.

Vaccines rely on strong health systems.

Costs will rise with rising coverage and new technologies.

Financial flows to frontline providers are a major bottleneck.

MICs also have financing challenges.

Alba Maria Ropero-Alvarez presented the Latin American experience.

We have mostly self-financing countries; only 5 are GAVI participants.

We have 99 percent self-financing of EPI.

The revolving fund is one pillar of our successes. Value of purchases: $545 m.

29/51 countries have vaccine legislation. This protects EPI sustainability. NITAGs have supported this process.

Achievements in LAC:

Strong immunization programs.

Challenges:

• fiscal constraints, especially in Venezuela
• Coverage declining in some countries
• Measles, diphtheria and YF outbreaks
• Cost to protect migrant populations, especially from Venezuela
• Legal frameworks, which need updating
• Maintenance of EPI as a priority within the new health sector reforms and decentralization.

[case study: Ecuador, with table showing challenges and recommendations amid PHC integration]

 

Lora Shimp-Carpenter pointed out that devolution requires, in Kenya and elsewhere, country-tailored budgeting approaches. Coastal and Nairobi had better understanding of costing than other areas. It took Kenya a year to recentralize vaccine procurement and another year to recentralize A-D procurement.

Counties need simple tools showing expenditure data.  In Q1 of the FY, services decline because of reduction in funds flow.

Some things need decentralization; others do not.

Respondents said that they had weak data on expenditure for social mob and M&E.

Respondents said that they had strong data on expenditure for training and surveillance.

In UNEPI, NUVI now exceeds ½ of total expenditure.

Household spending accounts for ¾ of total health expenditures in LICs. Donor spending, to have an impact, needs to be strategic and catalytic.

Household (domestic) funding has been falling in LICs.

In Nigeria and India, 0.9 percent of GDP is spent on health.

Among respondents, MoF mobilization and expenditure tracking are the first and second most difficult challenges. Mobilizing local resources at the district level comes in a close third.

The demand for immunization is driven by public demand. This means trust, especially trust in vaccines in an atmosphere of vaccine hesitancy. EPI can be the victim of its own success.

The EPI manager from Barbados said that immunization services are free, amid a declining fiscal space. Barbados has more NCDs which are driving health care costs in e.g. oncology.

Sin taxes on tobacco and alcohol should be regarded as public health measures, not as a revenue stream.

How to justify funding? Ulla Griffiths, UNICEF: journal publication will have little impact unless you disseminate results to decision makers.

Among respondents, most cited justifications were return on investment and morbidity/mortality reduction.

External missions of any kind should be the occasion for advocacy with health ministries for more spending on immunization.

COFFEE BREAK

The first breakout session, by Zipline, was on use of drones in the Rwanda supply chain.  devanshi@flyzipline.com

Drones can ensure rapid response for vaccine products with unpredictable demand. Can increase access in the hardest to reach areas.

There is risk of both expiry and stockout in peripheral areas.

We work with drones to reach all areas with speedy delivery. You save on costs of fuel and labor. We have an inflight computer that flies the drone itself.

We combine the pharmacy (blood transfusion) and airport in a single place. Ground transport would take four to six hours. When we get an order for transfusion blood, we can fulfill promptly. Blood is parachuted.

We don’t need landing pads at the periphery.

We service 16 facilities from our facility, outside Kigali. Blood is a just in time item. “This can be applied to vaccines as well.” There are 100s of EPI/ED delivery destinations.

Zipline has made 6000 deliveries, i.e., 12,000 units of blood. The emergency supply took up to 8 hours; now, it takes <30 minutes.

There is a risk of human error with vaccines, especially in areas without adequate refrigeration equipment.

The business case for vaccines:

• Increase access through campaigns
• Supply emergency vaccines with unpredictable demand
• Streamline logistics: eliminate stockouts, lower costs of soilage and expiry of vaccines

Antivenom and rabies vaccines are not part of RI.

The plane weighs 19 kg and can carry 2 kg.

Davis: When will you publish your results, especially on costing? The NLM database has no citations on drones in Rwanda. I don’t see a persuasive case for the use of drones to transport routine vaccines in Rwanda.

Have you modeled routine supply vs. emergency supply? We are doing both routine and emergency deliveries for transfusion blood.

What is your maintenance cost? Presenter did not quote a figure.

Yakubu: What if the consignment ends up on the roof? Answer: We have had only six such incidents, about once in a thousand deliveries.

The second breakout session, by GAVI, was on ACSM, with special attention to SDGs and the ADI, with engagement by heads of state. They place emphasis on national resource mobilization.

The panelists included Simon Wright, Save the Children, who spoke about civil society and its role in EPI advocacy. He said that advocacy is more difficult than other EPI functions. CSOs can work on reaching hard to reach populations. But our voice should be a key ally in health and EPI. Globally, we work on equity for coverage, using the rights based approach to health.

NUVI is one thing; equitable progress in access to vaccines is quite another. The CSO voice needs to be heard in global bodies like GAVI. CSOs can challenge vaccine prices (MSF, notably). In the UK, we use vaccination as exemplary when the NHS budget comes under attack. Governments need to tax, and EPI is a strong investment case, as part of an integrated PHC system.

A second panelist said that EPI and MoF are often speaking at cross purposes. You need economists to make the case for new vaccines, notably.

A Rwandan MP, Richard Sezibera, presented on mobilizing parliamentarians at the national level. GAVI has been a vaccination champion at the global level. The GAVI Board is a global driver. At the national level, we are structured differently, with an EPI manager and a NITAG. There is no broad array of advocates at the national level to champion the cause of vaccination.

MPs are not aware of the successes of vaccination. MPs need to be involved in planning for immunization, especially as we deal with transitions. MPs can also be advocates within their constituencies and with FBOs and other coalitions. But you need to provide them with data in digestible form.  Point out to MPs the cost of inaction. You don’t win an election on health.

Benjamin Hickler (sp?), UNICEF, is a communications specialist. The 2017 Indonesian MR campaign is cited as a success story. We have overcome problems by taking advocacy seriously. We had just experienced challenges with hesitancy in Tamil Nadu because we took vaccine acceptance for granted. We didn’t do the work to bring parents, pediatricians and others into the alliance. With a lot of work, we addressed those issues in India. We vaccinated 35 m kids in Phase 1 in Indonesia. Tactical things we did at low cost was monitoring sentiment on social channels before hesitancy became a problem, proactively responding before antivaccination came to the fore. We worked on coalition building at the local level. We cultivated a fertile environment for the national decision makers to hear the voices of the communities.

Responding to misinformation can be done in a bottom up way through monitoring of the social media.

Q and A: Why are we stuck with low coverage in Papua New Guinea?

Save the Children: What kind of civil society organizations do you have? Child mortality has been our driving concern. We want U5MR to assume a higher profile. We used this to get a bigger UK replenishment.

In India, HPV vaccinees died after snake bite and drowning. They closed down the HPV project after public uproar. We were asked not to speak to the media. We moved to Indonesia, then back to India, where two states have done demonstration projects with HPV. There is opposition; we have had to step back, then fight back.

Sezibera, Rwanda: We are an outlier. Kagame is on our side. Most finance ministers are a challenge. Marginal budgeting for bottlenecks has been a useful tool with finance ministers, especially in Rwanda. Health ministers are not strong in economics, and, hence, weak advocates.

LUNCH

Afternoon session: Business Case for WHO Immunization Activities on the African Continent

This session was chaired by Helen Rees. The old idea of doing good for doing good is still there, but the fresh idea looks at return on investment, for example. The RITAG view is for a document which speaks to these needs.  These needs include, for 2030, the SDGs.

Richard Sezibera will speak, but last. Our first panelist is Richard Mihigo. You have our business case at your tables. See also our Youtube item at https://www.youtube.com/watch?v=swyXsrJaoD4

Our plan covers all African countries, including the North African members of EMR.

We see a need to accelerate our efforts, fulfilling the Addis Ababa Declaration. Our new RD has put a strong emphasis on UHC, as has the new D-G, himself a son of Africa. We need to support all 54 member states on the continent, including 47 from AFR and 7 from EMR. How can we leverage new initiatives to support HSS and, through HSS, the SDGs?

The AFRO transformation agenda:

• Smart technical focus
• Pro-results values
• Partnerships and communications
• Response strategic operations

[graphic showing transition from today’s focus to tomorrow’s focus]

[graphic showing disease burden and mortality due to selected VPDs]:

• Rotavirus
• Pneumo
• Pertussis
• Measles
• Rubella/CRS
• Tetanus
• Diphtheria

Almost 3/5 of global mortality from VPDs is from Africa.

There is a multi-billion-dollar impact of VPDs on the African economy. There is a 37x return on investment with greater investments in vaccination.

[Immunization maturity grid based on development of the six immunization components]

The 54 AU countries have been categorized into four categories [Somalia at one end, Algeria at the other].

We then adopt our core functions in line with this categorization.

Our biggest donors:

• GAVI
• CDC
• Assessed contributions
• MVIP (malaria vaccine)

Patrick Lydon spoke next. HQ is navigating transitions for the world, notably post-GVAP. Key partners are ahead of the game:

CDC is preparing a country based EPI approach.

GAVI is developing its strategy for 2021-2025.

Other partners are doing the same.

This African business case was launched at this year’s WHA.

Before 2020, we have surveyed readers for their views on post-GVAP.

Most cited reasons:

1. 1.       need to reiterate importance of accelerating efforts to achieve GVAP goals post-2020.
2. 2.       Need for a strategy to address new and emerging issues in global immunization
3. 3.       Immunization has lost visibility within the global context.

Main objectives:

1. 1.       Prioritize future immunization efforts for collective action.
2. 2.       Reiterate value of investing in vaccines and EPI.
3. 3.       Describe and end game changing action and interventions to deliver on immunization outcomes.

Main focus:

1. 1.       Articulate a framework for how to drive change in countries
2. 2.       To describe why investing in immunization is imperative to reach UHC and SDG3
3. 3.       Describe what the global immunization needs to be prioritizing post-2020

New and emerging issues:

1. 1.       Reducing unimmunized, raise coverage and equity
2. 2.       Building national ownership
3. 3.       Expanding immunization along the life course
4. 4.       Reducing immunization gaps in MICs
5. 5.       Sustaining coverage gains
6. 6.       Immunization in fragile states
7. 7.       Surveillance
8. 8.       Demand creation and vaccine hesitancy

Substrategies needed:

1. 1.       Surveillance
2. 2.       Innovations in delivery
3. 3.       Strategy for raising coverage and equity
4. 4.       MICs
5. 5.       Integration

Helen Rees: there is a SAGE GVAP working group. We want to take discussions out of this group to that working group.

Katia Fernandez, WHO HQ, spoke next, on meningitis. “Defeating meningitis by 2030.”

MenAfriVac success showed that country ownership is key for success. There were 300,000 cases averted, 30,000 deaths prevented. Introduction was 2010 to 2017, with mass campaigns in 21 countries. We need to integrate this shot into RI.

Early detection and response to men C remains a challenge. We have 34,000 cases reported. We also have men W.

Wilton Park conference, May 2017: call for a new global plan to defeat meningitis by 2030. Ouagadougou meeting, September 20187: call for men as a global priority with 200 reps from 26 countries, plus key partners

WHO’s next Global Programme of Work is based on the SDGs. WHO’s mission is 3fold: promote health, keep the world safe, serve the vulnerable. Meningitis as a global priority embodies this threefold mission.

[graphic showing actions to defeat meningitis by 2030]

Fund raising is underway for preliminary implementation of selected elements.

Zipline is a California based logistics company that designs, manufactures, and operates drones to deliver critical medical products on demand [summary of their activities, page 31 of this report].

 

Richard Sezibera, of the GAVI Board and Rwandan senate, praised the African business plan. Most people prefer continuity over transition. At the global level, we have the right mix of people on the GAVI Board. How do we sell our successes within EPI as part of a larger UHC agenda, e.g. from cold chain to PHC supply chain? How do we support CHWs when they are doing EPI and other things? How do we work with WES?

The business case is an excellent idea. How do we navigate this new world?

Helen Rees asked the panelists to come to the front.

Discussion:

Jules Millogo, Merck, asked Sezibera what they needed from the business community.

Zipline asked what is the cost-effectiveness of drones compared to use of road networks.

Pascal, GAVI, asked how are we going to move towards integrated goals and objectives. Does it make sense to use 10-year rather than 5-year timelines?

Laurie Sawyer, UNF, said the business case is great. What’s the ask of us? Are you going to mobilize from African governments?

Sezibera said that the business community needs to be better involved. In Rwanda, Zipline is here. We had no drones. We need to be open to private sector as partners. Decision makers need to reach out to the business community and ask them what they should do to succeed.

Helen Rees said that we need to sort out regulatory issues.

Zipline: We have run our service for two years and are increasing our breadth of products. We think that transport savings are considerable.

Helen: Do you have figures on lives saved? Zipline: We are working on that calculation.

Helen: Can meningitis be pulled into the business plan? Katia: Africa is at the center of our meningitis focus. That fits within the business case, especially in terms of country impact.

 

CONCLUDING PLENARY SESSION

When we came into the plenary session after its start, Diana Changblanc was completing an electronic poll of participants concerning their views on how best to promote measles/rubella eradication post-2020. By far, the most popular response was “raising MCV1/MCV2 coverage.”

Diana then invited Robin Nandy to make some concluding remarks. It has been a busy three days, and we are close to the end. This will not be a long speech. Thanks to all who contributed to this meeting. Are we better placed now to navigate transitions? Pretty favorable feedback from your poll today. Thanks to all country participants for keeping us on track and providing a reality check. I hope we are going back re-energized and ready to meet the challenges we face. This meeting is a process, not a means to an end. Let’s keep the momentum going. We need both to focus on the urgent now; the other is to step up to the transitions.

Our partnerships are long standing, but they can get better. Senator Sezibera said that we should broaden our partnerships. Let us not be afraid to shift our positions. Let’s use data. Let’s use new information. D-G Tedros tells a story of a mother who cut the tail of the turkey before putting it in the oven. The grandmother said “Yes, because my oven was too small.” Sometimes we think small because of missing opportunities created by the larger oven. From UNICEF, we have many indicators to measure our performance. Remember that we have to keep pace with our changing world.

From my personal viewpoint, I enjoyed this experience, but regret not having left this complex. All the best to those of you who still have a team in the World Cup.