Strengthening the Health Workforce to Reach Global Immunization Goals

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This transcript is from a CSIS event hosted on October 3, 2023. Watch the full video here.

Nellie Bristol: Good afternoon, and welcome to the CSIS Global Health Policy Center. My name is Nellie Bristol. I’m a senior associate with the Center, filling in for my colleague Katherine Bliss who got called off to jury duty. And we’re here today to discuss the state of global immunization, in particular focusing on the state of the health workforce on recruitment, training, retention, and professional development to ensure that this workforce can reach – can provide lifesaving immunizations to everyone everywhere across the world.

We have a great panel today, a lot of expertise, and really excited about that. So I’m just going to give a quick intro and then I’m going to introduce my guests and they’re going to take it away.

As we all know, the pandemic was disruptive to health services throughout the world and in particular it was disruptive to immunizations. There was a – WHO and UNICEF reported the most significant decrease in immunization rates in three decades during the course of the pandemic, and there’s been some recovery from that but it’s been uneven and there’s a lot of stress among the health workforce and so we need to discuss what we can do to help them get the job done.

The CSIS bipartisan Alliance on Global Health Security Working Group on routine immunization as the platform for health security released a report in July 2023 with a recommendation focused on ensuring there is a health workforce prepared to deliver vaccinations and communicate effectively with parents and families about the importance of vaccination.

So we’re here today to discuss with this august group what steps we can take to recruit, train, and retain the health workforce that delivers immunizations, including preservice training and mentorship initiatives to prepare management for leadership positions.

So I’m here today with Anuradha Gupta, who has held high-level positions in the Indian government; served as deputy CEO at Gavi, the Vaccine Alliance; and is now president of Global Immunizations for the Sabin Vaccine Institute. Welcome, Anuradha.

Anuradha Gupta: Thank you.

Ms. Bristol: And Folake Olayinka – (laughs) – who has 25 years’ experience in health programs including leadership roles globally and at JSI, and is now immunization technical lead at USAID, correct?

And this is Lora Shimp, who has been at JSI since 1997 as senior immunization technical expert in communication and behavior change.

So welcome to you all. So we’re going to start off by having each of you talk about the two or three major challenges you see in developing a strong immunization workforce that can reach all children everywhere.

Anuradha, would you like to start?

Ms. Gupta: Yeah. So thank you, Nellie, for that question, and I do think that the state of immunization and the state of health workforce are inextricably intertwined. So when we look at the recovery post COVID-19 we also see recovery is slow, much slower than anticipated.

But we also see that this is uneven, and if we look at those regions and countries where we continue to see either stagnation or decline or, really, difficulty in bouncing back to pre-pandemic levels of coverage you can establish a correlation between health workforce paucity and this challenge around restoration of coverage.

So if we look at Africa, for example, you know, we know that Africa is one region where the shortage of health workforce is projected to be 5 million and is not projected to improve. In other regions there are, of course, improvements, you know, slow or fast but Africa is projected to continue to have the shortage.

And on the other hand, then you also have a growing birth cohort because of high fertility rates. So, really, by 2030 you have 5 million more children, you know, to be vaccinated every year, pushing the number to about 14 million children. So on the one hand you have the shortage of workforce, right, to actually make vaccinations happen and on the other hand you have the growing birth cohort and the growing number of children to be vaccinated.

So, to me, there are really four things which are important. One is knowledge – you know, knowledge of health workforce and the gaps that we continue to see. The second is really adaptive leadership. You know, this whole challenge of a lot of health workforce feeling that they are sort of lone wolf and sort of really lacking mechanisms to foster adaptive leadership.

The third is really communication and advocacy, you know, which equips them to bring communities along, and really the last thing is kind of an enabling supportive environment, you know, where they have buddies or mentors, right? So and I think all of us have experience with buddies and the value that buddies add and also mentors but I think for health workforce that’s also another area which is quite critical.

Ms. Bristol: Thank you.


Folake Olayinka: Thank you so much.

I’d just like to build on many of the points that Anuradha has just made. The health workforce is really critical for achieving the Immunization Agenda 2030 goals as well as the SDGs and universal health coverage. I mean, they’re just inextricably interrelated.

There are several challenges and maybe just to build on some of them, just looking at the adequacy and the availability in terms of the numbers and the relationship between the health worker density and UHC have been very well documented and established. Where you do have adequate density you tend to have, certainly, greater service delivery.

And so the – I would also add in that the last few years with the COVID-19 pandemic has further strained and exacerbated these shortages and gaps and so if you look at the recent 2020 national health worker count it’s estimated right now that there’s a current health worker shortage of about 15.4 million health workers, which is expected to improve – at least by 2030 projected to be at levels of about 10.2 million.

Anuradha has mentioned the Africa region is experiencing the most burden of that shortage, up to 50 percent, and so this is really related to the training capacity, the recruitment pathways, and the retention not just of those coming in but what – how are those who are exiting being replaced. So there’s the replacement pathways.

Within countries themselves there are inequities in terms of the distribution of health workers often concentrated within urban areas and where you have zero-dose children and inequities they’re often in the hard to reach, remote, and this is – these are places that health workers do not want to go and do not have an enabling environment in which to work and reside. So, again, you see that maldistribution come into play.

Maybe the last point I’ll just make is on the issue of an untapped resource and this is the community health workers, and there are a range of them, depending on their education level, their function. But we don’t have enough insight into how the – how to structure, how to supervise, how to adequately incentivize, how to move away from being volunteers into a more structured performance-based network.

And so one of the things that USAID and the U.S. government has done is to recognize the robust global health workforce is an integral part of delivering and achieving essential health services for everyone and so the Global Health Worker Initiative, which you may have heard about, was announced last spring and this – and also in the leaders meeting in December.

But the point I want to emphasize here is that this Global Health Worker Initiative really underscores and emphasizes the need to formalize the community health workforce and adequately compensate them and integrate them into the delivery of primary health-care services.

So that’s, certainly, a space that is underutilized and just want to put that out there. Thanks very much.

Ms. Bristol: OK. Thanks, Folake.


Lora Shimp: Thanks, Nellie. Thanks to CSIS also and thanks to those who are listening in and really appreciate this discussion because it’s really crucial, and four areas, building on what’s already been said, which is in full agreement, you know, there was a study done by BMJ in March 2022 talking about the needs for COVID vaccination health workforce and they estimated about 1.83 million additional health workers needed just for COVID vaccination in 61 countries to increase coverage to the 70 percent goal.

We never met that goal, even with COVID and additional resources for COVID. Those needs for a health workforce haven’t gone away and I really want to look for a first point at that – the need that we address this holistically, not vertically by program.

I think Mike Ryan in – who leads the WHO Health Emergencies had a wonderful quote nine months ago – I would look it up. It’s about a minute segment. Where he talked about the challenges with underpaid, overworked, under resourced, not respected health workers and the challenges in our health system’s lack of elasticity and resilience – that we built a lot on these networks in the past, including immunization programs that are 40, 50 years old but that we haven’t been able to keep up with the times when it comes to that health workforce competency, attrition, and other areas.

And in many cases we also haven’t dealt with some of the health worker needs in terms of their own mental health and other things. In that quote he mentioned that health workers were the last people that millions of people saw during COVID before they passed away, and the pressure on those health workers that we really have to acknowledge who – you know, some of them weren’t really trained to do emergency work and found themselves for two years in emergency settings.

So I think addressing those needs for attrition, job performance, holistically that’s one. Second, building on Folake’s point, the social versus institutional commitments to community health workers. We all agree that that CHWs are important. We’ve been looking at – Henry Perry and others have looked at this for decades but what we haven’t done is looked at their long-term commitments in countries the way that ASHAs in India or CHPS workers in Ghana. Are we really – the health development workforce in Ethiopia – are we really looking at going beyond volunteerism and really acknowledging the role that they play as critical frontline health providers?

Third, I really want to acknowledge something that’s happening with PAHO right now, which is a reorientation of health systems to primary health care. We have to go back to emphasizing prevention in primary health care. Immunization is fundamental to that. We’ve learned that. If there was one lesson that came out of COVID it was the importance of vaccination to get us back on track. So that really – that emphasis on preventive health and health workers’ competencies in preventive health is really necessary.

And, lastly, on the points around mentorship and coaching and other areas, that continuous improvement in learning for health workers, we have tagged a lot on to their responsibilities without really building the practical adaptability of guidance and tools for them.

There’s a lot that’s available in the global world. There are different e-fora. We have, you know, Boost Network, Geneva Learning Foundation, Gavi Learning Hub, community of practices. But a lot of that doesn’t translate at subnational levels and, really, what we need to do is be able to make that more practical at those, really, facility local levels.

Ms. Bristol: Well, let me – I’m going to follow up on your comments about community health workers and what are the obstacles to – I mean, obviously, money is going to be one of them, but they are – there’s a lot of volunteer community health workers around the world.

What are the obstacles to really professionalizing their industry, as it were, and making them integral parts of the health system itself?

Ms. Gupta: So I have had some experience with these community health workers in India where we actually – I stood up a cadre of 1 million accredited social health activists, right? So they’re called ASHAs, which is ray of hope, but actually it is accredited social health activists.

So who are – and they’re all women, right, so 1 million ASHAs in India – and who are these women, right? They are all residents of the same – of the community so they live in the community and there is one ASHA for a population of 250 so that means really about 50 households.

So that’s the sort of population they work with so a very manageable span. But what exactly were the issues that we faced? One is that ASHAs were supposed to be the interface between the health system and the community, you know. So they were not health-care providers because they were not trained to do that. But they were actually supposed to be improving health-seeking behavior, you know, and demand for services, and then really support the community in accessing health-care delivery, right?

So if there is a pregnant woman and has to go to the institution to deliver then ASHA would accompany that woman, right, and provide that support. And so there were very interesting issues, first of all, about them being volunteers. So how much of a load can you put on them and thinking that, you know, they would not expect a salary or remuneration.

So that was the first thing that – and when we said that they would get performance-based incentives who’s going to actually determine, you know, whether – what exactly are the tasks that they had performed and was the –

Ms. Bristol: And what was the reward.

Ms. Gupta: And – exactly. And then you know then how did they – how do they get their remuneration and delays and things like that.

So I think we realized that you have to give them some sort of basic remuneration assuming that they would perform a certain range of tasks so that at least they have some minimum amount of money in their hands but they also had certain incentives on top of that.

So I think that is a key learning and that then requires resources, and I think India could do it, these whole 1 million ASHAs, because the government was very committed to putting its own money because this kind of initiative can never be run on the strength of external funding, which is not sufficient and which is also time limited.

The second important thing that we found was this whole tension, you know, between the health-care providers and these community health workers because the system would not want to let go of the power that they had. So this whole issue of task shifting, you know, there were so many things that these community health workers could actually be trained to do very easily. But, you know, but they – these are those power dynamics.

So I think that’s another thing. That’s what I think Lora and Folake were saying about how do you structure it and how do you fight those power dynamics.

The third very interesting insight that I want to share is that, you know, when these ASHAs were recruited – you know, and it happened very, very quickly – a lot of people felt that they would become government employees at some point of time. So we saw an over representation from those households and communities which actually were quite up on the social hierarchy and, you know, when – and, of course, health outcomes in India began to improve but not to the extent that we were hoping, and then when we undertook an assessment we realized that these ASHAs were all from upper class and, you know, the lower class, the most marginalized, stigmatized populations, you know, we did not have ASHAs from those.

Ms. Bristol: So they couldn’t connect with –

Ms. Gupta: So they were – so they were still not visiting those households –

Ms. Bristol: OK. Yeah.

Ms. Gupta: – and were not connecting. So the issue of marginalization, exclusion, or persistent inequity really remained and then we, of course, adapted our policy and made sure.

And the last thing I would say is the opportunities for career development and advancement –

Ms. Shimp: Definitely.

Ms. Gupta: – you know, because a lot of them will say, well, they had done their 10th grade education but they had – a lot of them became so aspirational because they were so talented. So I think that’s how we then link them up with open university and open school education, and then also actually earmark certain positions from – for them in nursing schools and actually provided for certain structured space for their career advancement.

Ms. Shimp: And just to add on that, I think the incentives are important but they don’t always have to be monetary, and this is something that a lot of programs don’t really think about. You know, countries like Madagascar have had relais communautaire for decades. They have a very strong community system called folktani and you have the heads of the folktani with local leadership. A lot of times it’s just giving them free health care, for example, or free meals when they’re going out and working with the populations.

When we did an evaluation on health worker training and development in Ghana in several countries several years ago in talking with many of the CHPS workers, who do get some remuneration, most of them when we asked what they needed they said, we need boots for when we’re going out in the mud on these outreach visits, or we need a stethoscope because, you know, we want to be able to measure heartbeat. You know, things that that will help them do their job and their performance but that – you know, like you’re saying that need to be – sort of grow with them over time and get the community to also support.

And just on that also I would really – like, also acknowledging that volunteerism only goes so far. Years ago, in Madagascar we looked at attrition for some of the relais communautaire and it was an average of 30 percent a year and we see the same thing with health workforce in Kenya, Ghana, and elsewhere, that they either go to private sector, they go to external – you know, working in other countries.

So accounting for that attrition is also important. That’s where preservice comes in and growth pathways for community health workers so that they see also a desire to stay in the field.

Ms. Olayinka: Yeah. Maybe I can add a few points to what Lora and Anuradha have already highlighted and that’s the issue around the policies. If you – I mean, countries are relying on outdated policies and, yet, the world has changed. Immunization has become more complex and really trying to reach the zero-dose communities is going to take more innovation, more creative thinking. And so what we see is that the policies are not keeping up with what the future requirements in terms of even the personnel, and the community health workers can play a really important role in getting to that last mile.

Those zero-dose communities they are part of the communities and so really establishing that cadre and codifying it within policies is important. We know that the ability to sustain such cadres and maintain them will also require some level of budget provision. I think the issue of volunteerism is something that more and more there is acknowledgment that there’s only – there’s a limit –

Ms. Shimp: Exactly.

Ms. Olayinka: – to what we can expect volunteers can do and there’s much more that can be gained in terms of formalizing adequately renuminary and also building up that capacity within communities.

Maybe the other thing I would just add on here is also their supervision and how do you keep them updated. There are new vaccines periodically. Even last week there was – (laughter) – from the CH meetings there were at least three new vaccines that have been recommended into policy.

So how do you keep these cadres informed in terms of messaging and communicating with families and communities and caregivers because it plays such an important role. So I think these are some of the areas that we really need to look at.

But there are also a couple of excellent examples. Ethiopia is well documented in terms of the community health extension workers and how they really played an important role in their communities and helping to reduce childhood mortalities. Kenya government, for example, the current president Ruto has really emphasized his priority around universal health coverage and his commitment to recruiting over a hundred thousand community health workers in order to achieve the universal health coverage goal.

So I think there’s greater recognition and there are examples that, really, many countries can build on and learn from as they really formalize this structure.

Ms. Gupta: Could I build on this a little bit more?

Like Folake said, sometimes, you know, your policy environment remains very static. You know, it is not dynamic enough. So I think the whole world has now moved in the direction of, you know, swearing by universal health coverage, primary health care, integrated primary health care, and things like that. But I think what has really – but it hasn’t really translated into a true appreciation of what does it mean for the health workforce on the ground including community health workers.

For example, you know, when – in India we recruited ASHAs and trained them and so it was for a set of responsibilities. So they were very focused on reproductive and child health, right? But then suddenly we had this whole noncommunicable disease agenda and, you know, so it’s not just that the vaccines are expanding but really the whole expectation around the universal health coverage is very big and all kinds of new programs and interventions are being talked about.

So I think that then brings us to this whole critical issue that if – and this is what – this is the challenge that we faced in India that if you have an ASHA for 250 population of people then – and if you are actually increasing their breadth of responsibilities then probably you need to have an ASHA for 20 households – or 20 – and, you know, really increase the number of ASHAs. Because if you want them to do everything holistically, then it requires more time and more effort, and then really expecting that they will be able to see.

So I think these are the kind of constant shifts that are required, right, in real time, you know, so that the gap that we see now between global aspiration and global agendas and actually what is it that community health workers can deliver on the ground.

Ms. Bristol: Right. They are where the rubber hits the road, right.

And I was wondering – I was thinking the strain that health workers have been under because of the pandemic and a lot came down to community health workers in a lot of places. And, Lora, you and I were talking about this beforehand. It’s, like, what can we do to support the mental health of these workers and also – and they’re going into dangerous environments sometimes and they – you know, they went through this pandemic not only without the – what they needed to protect themselves but what they needed to take care of their patients in a lot of times and it seems like we’ve kind of – as we’ve just blown past the pandemic and have pandemic amnesia they’re also – I mean, they’re kind of stuck with this – having been through this horrible situation and with probably some level of PTSD as a result and what are – what is being done about that? Are there – is anybody talking about how to help some of this – the mental health issues?

Ms. Shimp: It’s such an important point and it’s their own mental health. It’s what health workers bring to the experience of care that they’re providing and then what the clients come in with in terms of the challenges they have getting to the service. Do they – do they have stock outs of vaccines? So they come for the service and then find that the vaccine is not available or they’re told to come back because it’s not a measles vaccination day.

And, you know, in the global community we have the demand hub that we’re looking at with service experience, with quality of care, better planning for services, really trying to look at that holistic nature of the caregiver journey and the health worker journey, and gender plays a huge role in that.

We often – we’re often talking about gender now but we’re not looking at the underlying issues with gender where, you know, a lot of health workers and the community health workers are female. So they have their own families. They have to get their kids out the door in the morning before they go to pick up the vaccines or worry about their transport. Is it safe? Is it – you know, are they going to be able to feel comfortable in their work environment in outreach or in a facility, particularly in urban areas or in fragile settings.

So I think, you know, being able to look at that also, and as Anuradha was saying, around some of that – that listening that’s necessary around what do they need to be mentored and really feel that they’re being listened to, not just piled on with more responsibilities or more requirements for what they do.

And, you know, I wanted to – on that note, too, around the different cadres and what Folake mentioned around Kenya and the point around attrition, the other thing that we do also have to look at is that continuum. One thing that we found was – you know, we have malaria vaccine coming in now. We have HPV vaccine that’s looking at adolescents in a different age group.

We have everything that we’ve learned around life-course vaccination with COVID in adult populations, elderly populations, that immunization programs weren’t designed around. They were designed around children under one year of age and talking to parents. Now we have whole other cadres and none of that is in preservice training.

We found in Kenya years ago that most of the preservice was around giving injections, the actual, you know – and maybe a little bit on data. Now they’re expected to do data. They’re expected to counsel. They’re expected to reach out to, you know, other groups and, you know, we aren’t very good also about addressing partners who can help us with this like International Council of Nursing or these nursing associations who can help us with that mentoring and really bring the different cadre into that holistic way from preservice, in-service, and then opportunities for peer exchange.

We know so much about closed groups in the sense of WhatsApp. All of the health workers pretty much across the world have their own WhatsApp groups now. But what we need is to be able to work with those on their training and their questions because for younger health workers, or CHWs, they might be embarrassed to ask some of these questions where the older ones may have difficulty with the technology. And so we have to learn at their – help them learn at their levels and I think that’s something that in the digital health world we’re trying to address but we have to look at it in a blended learning concrete way that – you know, not digital alone. Digital alone won’t solve it but also we need digital to help us.

Ms. Gupta: Yeah, but also talking about digital tools I think there are two sides of this issue. One is that, yes, digital tools can help. But if we do not reimagine the paperwork that is required to be done then you’re actually increasing the load on the health workforce and this is what has typically happened in all countries where, you know, there – of course, there is now insistence that health workforce, you know, uses all kinds of even iPads and, you know, all kinds of new digital applications.

But the insistence on maintaining paper-based records remains unchanged. So I think that’s where – that’s something that –

Ms. Bristol Who was insisting on that? Where does it come from?

Ms. Gupta: The system.

Ms. Bristol: OK.

Ms. Gupta: The system hasn’t been revalued. So you had these age-old requirements of maintaining certain records. And also when – in most of the low and middle income countries when digital tools are being adopted it’s not universal adoption. You continue to see gaps and I think that just makes the system so apprehensive and fearful, you know, that they’re unable to get rid of the paper-based system and – because they want this to be foolproof and therefore you have this whole combination of digital tools plus this with actually health workforce getting more stressed out.

But I think there is just one but there is another angle and that is what we realized at Sabin, you know, when we stood up this Boost Community and this Boost platform actually was started just with the onset of the pandemic it so happened and it became completely virtual and online.

And I think that the – that demonstrated the power of sort of the digital tools in enabling unprecedented kind of reach because now in two years’ time there are 4,500 professionals who have become a part of Boost Community in 150 countries, and I think when you were speaking about subnational professionals now they have made it possible, you know, for Boost to actually have 33 percent of community members from the subnational level and we now have so many inspiring stories of early career, you know, nurses and midwives and other professionals who are saying that simple tools like WhatsApp groups and Telegram sort of applications had actually helped them to reach out to other members of the community and actually seek support whenever they had some issue.

Ms. Olayinka: Yeah. I can just chip in a little bit in terms of the digital tools and innovations that have really come to the fore during the last three, three-plus years during the pandemic where a lot of countries and partners really had to pivot quickly to remote learning, digital tools for real-time data, surveillance tools that could rapidly get the information for decision making, how to communicate across countries.

And so tools that help with learning and capacity building. Webinars became very, very prominent in the last few years as the way that many people connected with getting updated information and learning.

But even in smaller groups and networks there was this study that one of our projects, MOMENTUM Routine Immunization Transformation Equity, conducted and they looked across 35 countries to get a sense of how much people have connected with learning through these digital platforms, and more than 60 percent of the respondents really said that the remote learning tools, the webinars, the internet searches – that was an interesting one, that people are searching for information, literature, publications, to support their decision making.

These were named as really important digital tools to help with the learning. But I would also add that at USAID we do have a holistic digital health strategy which brings in all the elements, several that Anuradha was talking about. How do you have a forward-looking approach to digital tools that is sustainable, that continues to build on the infrastructure? If you don’t have appropriate level internet, you know, you probably need to modify or plan towards increasing bandwidth and we saw that in a lot of places. Offline function, online functions, but also building in the investments that are needed to build up that infrastructure and networks.

Now, the digital tools, I would say, are not just for learning. I mean, I talked about the data analytics, the ability to get that real-time data and to use it whether it’s on Tablets, it’s on mobile phones, text message, or even more dashboards that people could run, see the different analytics. So important for decision making, and I would say in terms of immunization there’s been a greater use around the GIS and geospatial tools helping to analyze and create clarity in terms of where are the children that are being missed, who is not getting vaccination, and using that to build on other important in-depth analysis and studies in terms of the why so you can find out where, who, but then you need to couple this with the why. And so these have really been important advancements that we need to continue to build on.

Ms. Bristol: Are there other things that came out of the pandemic that you think are useful to this point and should be continued? You know, there – I mean, I know there was a – you know, a lot of countries had to sort of ad hoc come up with capacities to deal with what was going on, and in the immunization space is there – are there things that you think should be continued and should be funded?

Ms. Gupta: So I think one of the things that Folake said was GIS. So there were already certain things that had started to happen, right? But I think the pandemic actually just fast tracked that a lot. So I – we saw a lot of leapfrogging, you know. So, for example, you know, GIS was happening but at a much smaller scale, you know, in several countries but suddenly it was scaled up because people found it very, very useful.

I would also give the example of DHIS2 because when I was at Gavi we invested a great deal, actually brought WHO, you know, behind that to say, OK, we – let’s –

Ms. Bristol: Can you say what that is for people who don’t understand?

Ms. Gupta: So this is a health information system, right, which is district based and actually gives you good data in real time so and in the past there were multiple, multiple data systems that were floating around and so interoperability of those systems was actually a problem but also standardization was a huge challenge.

So when I was at Gavi I think – and all of us were very concerned about data. That is the time when we tried to actually build some consensus around what system would the global institutions recommend to the countries. So actually WHO, Global Fund, Gavi, we came together and University of Oslo was really the university that was developing the software and the program.

So we all came together and we actually encouraged countries to adopt this particular health information system, and then what happened was that it got scaled up in more than 50 countries. But during pandemic what we saw was that people started to use that and actually built COVID-19 surveillance modules as a part of DHIS2. So, you know, so there was local innovation, the country saying, oh, but this is really such a rich mine of data and they can actually use it to monitor COVID-19 trends.

Ms. Shimp: Building on that, though, I think one of the things, you know, as – what we have learned from the pandemic, too – (inaudible) – immunization, there is no golden cure. There’s no magic bullet, so to speak, and so digital is not going to solve all of the issues like we said.

It’s making work easier. But we also have to check our assumptions around empowering people to use the data that they collect themselves, not feeding it up through a system where then they don’t see real time themselves the input that they’re generating but, rather, making sure that as we’re growing these systems we’re not only building the capacity of the people on the ground who do that input because, you know, we have gotten away a little bit from some of the fundamentals of immunization – the coverage graphing, the tracking of populations – that we used to have at a very paper-based level that now is much easier with digital. But the feedback loops have not happened.

And so we’ve been doing with Gavi resourcing this routine immunization training module, the training in India, on – app based which was rolled out during COVID for thousands of health workers across the country. Critical to that is the government’s commitment to this. The government is helping to resource this. The tools are based on previous medical officer handbooks, nursing handbooks.

So there’s a fundamental base of knowledge that’s already expected – we talked about the ANMs and the ASHAs – so that when you add the digital you already have a foundation of learning that’s there that you can expand and build on and then helping them work through some of the blended learning that’s needed to just – you know, like, you need to practice stocking vaccine in a refrigerator. You need to practice using data and analyzing it so you understand what’s in front of you and how you’re going to pivot your program.

So I think that’s one of the things, too, that we learned. Don’t come in with a precooked solution, particularly if it’s from a higher income country, and assume that automatically the government in another country can adapt and do that, like, plug and play. And I think that’s really – you know, we need to be fostering a lot more in the policy area around these digital health and learning strategies that countries can maintain and build.

Ms. Olayinka: I think one of the things that we’re really emphasizing and we are using, integrating more and more in our work, is the concept of co-creation. So you’re looking at problem solving but this is together with those who are actually providing the service, who are providing the policy, but also who are using the service and the communities all coming together.

And so this is actually one of the methodologies that we think has been very important and successful in a number of countries, and even just human-centered design. So when you talk about technology – I think, Lora, you were mentioning it earlier – that you also – and Anuradha as well – you also need to have a change of mindset in terms of those who are actually using the digital tools. Health workers who have been used to filling paper forms there needs to be an orientation in terms of change management that moving to digital tools is going to be more helpful to their work, more relevant, will give them greater efficiencies.

Of course, that is if they’re not doing both paper and digital tools – (laughter) – which – so I think there are these aspects that we need to really bring together as we look at how to leverage and use the digital tools that have really come out during this pandemic.

Ms. Gupta: I think there – sorry. I think there is – from my perspective, there is a very interesting lesson that came out of the pandemic. One is that there is no one size fit all approach. So I think just countries are so heterogeneous but also within countries the provinces, the districts, the communities, habitations, are just so heterogeneous that they require, really, very different solutions and I think the pandemic just made it even more evident.

There’s this – the discourse had already started but – and the second, I think, important thing that happened was to really – an acknowledgement that it cannot be top down and prescriptive because I think in the past the global world had sort of, you know, always believed that it has better solutions, right, and that, you know, those solutions can just be passed on to countries.

But I think during the pandemic in particular we saw a lot of local ingenuity and a lot of local innovation. For example, I remember that in India when – I wasn’t with Gavi but I was managing the national health mission – we used actually Gavi’s support to do this electronic vaccine management, right, even – so it was a very intelligent system of actually tracking your vaccines and also monitoring the temperature of vaccines, which at that point of time was a pathfinder and, finally, now it’s, of course, universalized.

But then during the pandemic, with a bit of support from Gavi the government of India was able to, you know, just scale that up and change even into COVID. You know, it became such a sort of widely acclaimed best practice because this did everything, right, from prioritizing populations to, you know, monitoring the travel and stocks of vaccines to even issuing certificates to everybody and making sure there was no pilferage or diversion of vaccines. So I think during the pandemic it became very obvious to people what is possible, you know.

Ms. Shimp: One other last thing that we haven’t really talked about but that the pandemic definitely demonstrated – and this was already being discussed before COVID hit – is the differences between urban and rural and peri-urban.

And, you know, COVID started as an urban issue, right? More people, more circulation. We’re often used to many of the outbreaks happening in rural – well, we have urban outbreaks also in other areas, measles epidemics, for example – but really understanding too that the contextualization for a health worker is going to be very different depending on their work environment in fragile, rural, peri-urban, and urban settings and we do need to design their performance support based on those ecosystem realities of where they’re – where they’re based and the expectations that might come with that.

Ms. Bristol: So we’ve talked a lot about the people who are actually doing this work. Let’s talk about the supervisory level and how you create that and connect it to the people they’re supervising but also how do you – how do you create a system where people can move up into that, who know the context? What are some thoughts around creating sort of the management level for –

Ms. Olayinka: Maybe I can kick us off on that point. I think one thing that’s really very clear is the upskilling and the competencies that are needed to perform within an increasingly complex immunization environment and I really want to emphasize that immunization as part of a broader primary health care, as part of essential services, and this is where the issue of access to training, mentorship, comes in but also the structure.

Let me also add here something very critical that’s come up before and that’s adaptive management, and because problem solving is a skill it cannot be didactic and so, really, part of the capacity development that we are looking at in terms of supporting countries is building that capacity to take learning, evidence, problem-solving abilities, as issues come up at the local level.

And, again, I think the emphasis is that there can be local solutions to local problems. It doesn’t always have to be a big national or big international solution. The local solutions can be very effective. I think we need to create more confidence and visibility. There are a lot of communities that are bringing local solutions to the issues that they face. So adaptive management, opportunities for supervision, competency, training, but also a very clear structure.

Now, I will just go back to the issue of the community health extension workers in Ethiopia. I think it was along the way that they realized there needs to be another step in which there is a career pathway. How do strong-performing CHEWs become supervisors? From the supervisory level is there a pathway to move into other cadres, formal nursing or physicians or so on and so forth?

So creating these career pathways. Again, there’s a lot we can learn from so that we’re not making the same mistakes and we can gain efficiencies faster. But I think these are some of the thoughts.

Ms. Shimp: Building on that, too, there’s sort of the supportive and enabling environment along these different pathways and also a recognition that immunization has a tendency to be over medicalized. We certainly know this in Europe. Look at France’s system. (Laughs.) But also that issue of the epidemiology and the public health aspects of this in addition to the training that you get for your curative care or giving the injections, like I said earlier.

There’s an assumption that as people move up in their careers in the immunization space that they’ve had leadership training, that they’ve had management competencies. But a lot of them entered this through the medical cadre, not through an epidemiology or management framework.

So even in the training that we’ve done through mid-level management training, immunization, and practice a lot of that has not gone around that management and supervision and peer sort of blended learning approaches. So Gates Foundation and others have funded, like, Teach to Reach and other opportunities to really get academic learning and management competencies along with the technical and epidemiology, and I think we need to help many ministry of health programs in countries to look at that in that more holistic framework as well.

When we were looking at this several years ago in Tanzania, for example, it’s interesting to look at Tanzania’s system where the people who’ve become the district immunization officer or the regional immunization officer – DIVO/RIVO – they actually go through more of an epidemiology training than a medical training. In other countries it’s all medical.

So you also have to look at what the structure is in the country to help emphasize those different competencies depending on what you anticipate that person – the career path that they go in. If you intend to have them have more management responsibilities or supervision then you need to prepare them for that trajectory beyond maybe the clinical training that they had in the beginning.

Ms. Gupta: If I could also add one perspective and that is that I think this whole thing about people who are doing clinical practice and then getting into higher public health management responsibilities and the kind of gap or dichotomy that we see there because we have not approached issues from a public health standpoint in the past because their approach is very patient centric.

So I think there is a gap there in terms of just epidemiological technical knowledge and understanding. But I think there is a – and we, of course, saw even during pandemic that there were – there was a health workforce that was actually also reluctant to take vaccines and I think it is – and we shouldn’t forget that because there were so many health workers who were actually very cautious and were not convinced about the value of COVID-19 vaccines and that hesitancy then drove a community level hesitancy.

So I think one is this whole technical knowledge gap. But the second – and that’s our experience and that’s my experience in India but also that’s the experience now that we look at through Sabin programming where we have seen that if we – you actually bring adaptive leadership layers, you know, then the kind of magic you create because through that adaptive leadership and community organizing leadership modules you are bolstering their self-confidence and you are actually getting them focused on their own ability to solve problems and those problems – those solutions could look very different in different contexts.

And I do want to share one particular example which really intrigued me so much because there was this frontline public health professional who said that during COVID-19 – and he was a Boost fellow, and he went in the community door to door and he found within a community there were households that wanted integrated delivery of COVID-19 vaccines and routine immunization. But there were certain other households who said don’t combine the two because, you know, it is going to be counterproductive.

So sometimes we are thinking that a community is really, you know, homogeneous but even a community is not homogeneous and when we empower these adaptive leadership skills to professionals I think it just prepares them so much better to really understand the social and behavioral drivers or if we are talking about human centric – human-centered design of services it just makes them much more understanding of those requirements.

Ms. Olayinka: There’s one dimension I want to just bring up very briefly since we’re talking about supervision and moving – growing in leadership is the gender aspect. Sixty-seven percent of health-care workers are women but only 25 percent are actually within leadership cadres and this is – you know, again, when you look at the quality, the availability of service, where those gaps are, having a gender transformative approach and gender equity is really going to be critical and this is where that gender transformative policy is important.

Otherwise, women get left off supervisory and leadership roles because they are – have multiple burden of household care, work care, care of sick family and community, underpaid, and just don’t have the same opportunities for leadership and growth.

So I think this is a very important priority for us at USAID in terms of ensuring gender transformative approaches are integrated into the work that we do. We’ve just finished a – we are in a collaboration with the Sabin Institute looking at having a gender course – gender and immunization course both in English and French as part of helping to raise the profile and attention to gender transformative approaches and integrating that into our work.

Ms. Gupta: And I just want to bring another dimension to this, right, Folake, and that’s exactly what you said. When we look at our Boost Community sort of a breakdown we found that only 26 percent of our 4,500 professionals are women and, you know, that for us has been a wakeup call because I said, you know, why is it when we say 70 percent of our health workforce is women but then we are creating this whole Boost Community and so many wonderful opportunities for leadership you have only 26 percent participation from women.

So now our new strategy actually is focused on deliberately growing the number of women professionals as a part of the Boost Community, but then I think for us to really interrogate some of the reasons that, you know, women are just so stretched because, you know, they are just overburdened with their work responsibilities but also their private life related responsibilities and, therefore, anything extra, you know, that is something that – but also I think important to remain cognizant that a lot of time women also suffer from imposter syndrome.

You know, so I think just – and they really need something special and something extra to really build their confidence and I will – so there is this program, you know, WomenLift Health, right, where, you know, we were having this –

Ms. Olayinka: The first cohort.

Ms. Gupta: Exactly. So we –

Ms. Shimp: Yeah, Folake was – (laughter).

Ms. Gupta: Yeah. So that’s going to be –

Ms. Shimp: Folake’s – (inaudible). (Laughter.)

Ms. Gupta: So I think this whole thing of sort of, no, women do need something special and something extra, you know, in order to support them and I think we just absolutely have to acknowledge that and, therefore, I – one of the discussions that we are having is whether within Boost Community and the kind of trainings that we are structuring, whether there is a possibility for us – a potential for us to actually give something extra to everything.

Ms. Bristol: Interesting. So we’re – oh, we’re really running out of time here. I was going to take maybe one question from our studio audience – not our studio audience, our online audience.

What role can the private sector play in supporting immunization workers?

Ms. Olayinka: Let me just very quickly – this is another area where we have underutilized this network and this is private, for profit, nonprofit, faith based, and oftentimes in – especially in very hard to reach fragile conflict settings they’re the ones that are able to access these communities and provide service.

So I think for us to really close the gap on zero-dose agenda they will become certainly much more important and we actually just finished a systematic review where we’ve looked at the roles and the – of private sector and the best practices. I’ll be happy to share that around. But I think a huge resource there.

But, Lora?

Ms. Shimp: Yeah. Folake mentioned M-RITE that has been looking at some of the health workforce issues, public-private sector, operational needs, and other things. What we really – there’s corporate social responsibility. There’s the engagement of some of these professional learning opportunities that private sector brings and we don’t often bring them to the table in coordinating committees or in the joint appraisals that Gavi is doing or other things where, perhaps, they can also provide expertise and on-ground mentoring and other capabilities that often have not been linked with the public health – the public sector program and I think that’s where some of these partnerships are really beneficial, particularly, you know, groups like Merck and others have funded training in the past provided it’s not affiliated with their product.

There’s a lot that they can bring just in general knowledge building around vaccination, around confidence building, communication skills with clients – you know, things that are agnostic in terms of who’s providing that service but that the private sector has a lot of learning and that could go into immunization programs.

Ms. Gupta: I also think innovation is another thing – you know, that when private sector brings that forward, you know, that can ease the burden on health workforce a lot. For example, very recently now there is this vaccine Land Rover, you know, which is a new kind of a Land Rover in which B Medical Systems actually has fixed cold chain. And that has just suddenly changed things for health workforce because now, rather than them trekking down, you know, miles and miles and miles, actually there is this very well-equipped van that can transport vaccines to the last mile and make it so much easier for them. So at least the delivery of vaccines or the carriage of vaccines.

So currently this is being studied in three countries but actually can be a – and it’s not – I mean, it’s a simple breakthrough. It is just – it’s not something rocket science but just understanding – you know, trying to not just listen but also understand what exactly are the pain points that the health workforce typically are confronted with.

Ms. Bristol: OK. Well, I think that we are out of time. I’m just going to do a quick summary here.

So the importance of community health workers but the importance of not just continuing to pile on tasks for them, making sure we’re providing supervision and support – mental health support in addition to financial support, adaptive local leadership, co-creating, so making sure that the people who are doing the work are involved in providing the solutions – identifying the problems and providing the solutions, figuring out how to get more women in particular involved in management training and getting the private sector involved in innovation and delivery and in passing knowledge along.

And I guess that was a great rich discussion and thank you so much to all three of you and good luck in all your work.

Ms. Shimp: Thank you.

Ms. Olayinka: Thank you so much, Nellie.

Ms. Gupta: Thank you.