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Vertical and Integrated Programs: Why Well-Funded Vertical Programs May Be Mistrusted

Here, Svea Closser describes challenges that can arise from a laser focus on a vertical program.
SVEA CLOSSER: One of the challenges that polio eradication has faced is that it’s become politicized and mistrusted in many areas. And to get at the reasons for this, we want to go through a few examples with you from the DRC and from Nigeria to understand why people might refuse vaccines and to sort of peel back the layers that go into people’s mistrust of vaccine. So to do that we’re going to start with a tool that UNICEF has promoted within polio eradication that’s called the root cause identification tool. So let’s walk through this for a minute. And if you could take notes on it, I’m going to have you use it in these examples that come up.
You don’t have to write down all of these boxes because as you can see, many of them repeat themselves. It’s actually simpler than this graph makes it look. So the first step is to identify the problem. So first thing you’re going to do with these examples is you’re going to identify what is the problem. So the example that UNICEF gives here is 70% of the community thinks that giving the oral polio vaccine is a somewhat good idea. That’s not quite as enthusiastic as you’d want. So then you say, why? What’s causing this problem? So you look for the cause of that problem. The example here would be 80% of the community is not concerned about polio.
Then you ask why again. You’re sort of acting like a two-year-old here. Every time you come up with an answer, you’re saying, why is that the case? Why is that the case? You keep going. Why is 80% of the community not concerned about polio? The answer that UNICEF gives is that, oh, 70% of the community believes that the symptoms are curable. Why do they believe that? So you’re going back another step. In this example, UNICEF is saying that, oh, in this case, traditional healers are a trusted source of medical information and say that medicine is only for curative purposes. So that might be one example.
So what I want you to do in examples coming up is go through this root cause identification. You can think of it as the two-year-old method. For everything that you come up with, ask why. What is the cause of that? See if you can get deeper into some of the root causes of what’s going on. Because if we don’t address the root causes, we won’t be able to solve the problems. Here’s a quote from a parent, and I want you to think about what are maybe some of the root causes at work here. “I refused the vaccine because of God. In the Bible, Matthew speaks of King Herod.
He had learned that a baby king was born in the country, and he went to the hospital. He went there to kill all children aged zero to five.
Matthew’s Epistle, 1:1 to 50. At the time we saw polio in the hospital, we also saw the polio vaccine that was distributed free of charge. The vaccine is also for children from zero to five years old. How can one explain that?” So what I would like you to do is think about what are some of the root causes at work behind this parent’s concerns. So take a minute and see how deep you might be able to go. It’s a little challenging if you don’t know the DRC well, but thinking about maybe some similar examples you may know from your own experience. Try to get some of those root causes.
And you can pause the video to do this if you’d like, and then when you’re ready to look at the next slide, you can restart. So here’s some more from the same parent which may help you get a little deeper into some root causes. “In 1880, when the church arrived, we were told to stop our natural medicine practices and bleeding. Whites told us, ‘Stop using drugs to protect yourself. Stop protecting yourself.’ The only true healer is God, so we eliminated our ways of doing things. And after that, the white man came back and said, ‘Come on, this time I’ll give you medicine to protect you.’” So does this quote add any layers to the root causes you had?
You can pause the video again and see if you can add some more root causes. So if I were doing this exercise, one thing I would say is that refusals are complicated and they’re historically deep. So in this example, it’s easy to chalk this up as something like, oh religion. This person is religious, so they’re refusing. But that’s a little too simple. This is about the history of colonialism. It’s also about current events. It’s probably about politics, the relationships between this parent and local political leaders. So all of these multi-layered levels are feeding into this person’s distrust of polio vaccine.
So simply having messaging about, oh, polio vaccine is good for your kid, isn’t likely to get at some of these really complex layers. And ideas about foreign intervention in particular often feed into vaccine hesitancy. So here’s another example that I want to do the root causes analysis with. This one’s from Nigeria, and it’s a religious leader. So this religious leader says, “In 2000 and 2001, when we shared our fears and concerns about the possibility that the vaccine might contain substances that could render populations infertile, we were told that the drugs were WHO-certified, and were manufactured in the best manufacturing environment, and the vaccine did not contain any other ingredients. We wanted concrete evidence but we only had words.
The fears of my people are not the same as those of Zimbabwe where people thought the vaccine would turn people into pigs. Our fears are more about medical issues. But what are you looking for? What is WHO looking for? What is UNICEF looking for? Why this relentlessness? How much money is spent in Nigeria to stop 109 cases? How many children die from measles, malaria, diarrhea?” So as we did before, if you want to take a minute and pause the video and see if you can get to root causes of why this religious leader is concerned about polio vaccine. So some answers I might have here is that there’s some distrust in international organizations, particularly in their focus on polio.
I mean he’s saying how much money is spent in Nigeria to stop 109 cases. That’s how many cases of polio there had been in Nigeria. He’s comparing that to burden of disease from other diseases, which are far, far greater, and asking why there’s so much focus on one disease. That’s making him nervous. There’s some deeper root causes beneath that as well. As a side note, I’m not actually sure that people in Zimbabwe thought the vaccine would turn people in the pigs. But the idea is that he’s making the point that his fears are not irrational. He really wants evidence. He wants data, and he doesn’t understand why WHO and UNICEF are making the choices they’re making.
So let’s look at some more from the same religious leader, see if it helps us more with root causes of his concern. “When you’ve come to vaccinate the population, you tell us that you’ve reached 60, 70, or 100,000 people, but all children in the state are vaccinated. Then you come back the next day and say there was a new case, and you have to re-vaccinate the whole state. What does this mean about the effectiveness of the vaccine? Nobody knows what’s going on. You come. You vaccinate. You collect money, and the following year, you come back to vaccinate the same children.”
So take a minute and see if you can get deeper into some of the root causes that might be going on behind this religious leader’s concerns. What I take from this quote is that the religious leader is really asking for more information, that there’s a distrust of international organizations that’s, again, in the Nigerian context, quite well founded given historical experience with foreign intervention and some vaccine trials actually that happened in Nigeria. It’s not unreasonable for people to be concerned. And in this case, the religious leader is concerned about this issue of these positive messages that are getting put out by polio eradication about how well it’s going, how many children are getting vaccinated.
And then when polio isn’t eradicated, this religious leader is getting more concerned and less trustful. So this, in part, goes back to some of the issues around addressing fatigue and distrust in endemic contexts that we talked about before. Nigeria, of course, has been polio endemic for a long time. It certainly was at the time this quote was taken. But thinking about not just people’s ideas about polio, but also people’s ideas about international organizations and the fact that they may not have been told the entire story about how complex this is and how difficult it is. And that may have led to some really understandable concerns. So here’s what a community health worker in Nigeria had to say about these issues.
Quote, “The members of the communities always complain about the constant visits to house to house, mainly only on the polio activities. Sincerely speaking, the public is so suspicious about the campaign on polio. People need malaria tablets more than polio vaccine. Some people complain that when fuel prices were increased, nothing was done to console the poor. But when polio was rejected by the poor, the government and the community elders were used to persuade people to accept it. If boreholes and other essential amenities should be provided to these communities, the polio vaccine would be more acceptable.”
So here you have a community health worker making the argument that when there’s this focus just on polio and not on other issues, this is something that inherently makes people nervous. They wonder, what’s going on when these international organizations that don’t seem to care about our kids for any other disease seem to care so much just about this one disease. And people start to wonder if, oh, maybe there’s some ulterior motive here. Or maybe this is not exactly what it seems. And it’s, of course, not the majority of parents that feel this way.
But if enough are a little bit nervous that they start to refuse vaccine, that can get in the way of eliminating the disease and leads to more and more campaigns, which unfortunately, can reinforce those sorts of concerns. So this brings us back to the opening of the section that actually understanding the relationship between vertical programs and broader health systems can be really, really critical for understanding vaccine refusals when you’re looking at eradication programs in particular. So thinking about ways to provide broad health services to people can actually be really important in allaying some of their fears around a specific vaccine. So here are some takeaways. Vaccine refusals are not just about misinformation. Sometimes they are.
Those are very simple to correct. People are just misinformed. You can give them the correct information and then they will accept vaccine. In many, many cases, reality is much more complex than that. So just telling people the right information or getting mad at them because they don’t believe the right information is not going to get you where you want to be. Vaccine refusals are also about more than local culture. Of course, people’s local cultural networks and norms are going to affect the way they think about and talk about vaccination, but that’s not the whole story. Vaccine refusals are very complex. They’re political and they’re historical.
They have to do with people’s power relationships, who they’ve historically had good relationships with, who they have reason to mistrust, and who’s approaching them with a given vaccine. They also have to do with trust in the health system, which in turn, has to do with the quality of the health system. If a health system is very poor quality, people naturally aren’t going to trust it as much. So the point is addressing vaccine refusals is very complex, and programs addressing vaccine refusals have to be extremely sophisticated to deal with these interrelated and complex reasons that people may be hesitant about vaccines. I want to take a moment here and talk about the role of religious language in framing refusals.
So many people refusing vaccine may use religious language to do so, as we saw in the case of DRC. In South Asia, people in polio’s last strongholds happen to be Muslim and many of them frame their refusals in Islamic terms. But being Muslim in and of itself doesn’t drive refusal. The vast majority of Muslims globally accept polio vaccine, and most major Muslim religious leaders worldwide support polio vaccination. As this image shows, polio vaccination may actually be required for people from polio endemic countries when they go on the Hajj. But Islamic discourses do shape how refusals are talked about, and it’s important to understand how people are thinking about and talking about vaccine hesitancy if you’re trying to communicate with them.
Many people who distrust polio vaccine draw on ideas about Islam as a potential alternative paradigm to Western domination when they talk about their resistance to vaccination. So is the issue about religion or about Islam? Sure, in the sense that that frame is very meaningful to people who might distrust the people providing polio vaccine. And a good communications program has to take that into account. But it’s also not about religion in the sense that religious belief is not a sufficient explanation when it comes to designing a good communication program since it may disregard some root causes. So it’s important to be careful here.
Framing vaccine refusal as a Muslim problem can cause further alienation and further communications breakdowns if the full range of root causes of refusal are not considered. So in the case of polio, it’s also global policy decisions. In fact, funding for the polio program itself has paradoxically contributed to some vaccine hesitancy in some places. In certain ways, the program has been a victim of its own success because it’s been so good at mobilizing funds, because it’s been so good at getting governments on board, because it’s been so good at reaching every single child with polio vaccine.
This has actually led to some concerns and parents who haven’t gotten any other services saying, wait a minute, why am I only getting polio services and not these other services? So this image of a house in Bihar, India shows just how many campaigns there may be. The side of this house is blanketed in polio team markings. So each of these markings here was from a different campaign when polio team came by in March. They’d come by and vaccinated kids. And when you have these really well-funded, frequent polio campaigns, if that’s paired with a health system that provides little, if any of what people need, it’s a dynamic that will drive distrust. The situation can be suspicious to people.
Why are polio vaccines being delivered to our doorstep when the medicines we need are chronically unavailable at the health post. A health worker in Nigeria explained quote, “People say they’re a misplaced priority.” A contributing factor to the disconnect is the relative lack of availability of international aid funds and international pressure for basic health service provision. So thinking about primary health care and the importance of wide-ranging basic health services that provide what people need. So these images are of crumbling health infrastructure in two areas that are polio endemic. And both of these places have had long, ongoing polio campaigns.
So despite rhetoric about the need to improve health systems, most global health donors are currently focusing largely on disease-specific interventions rather than integrated support for health systems. And paradoxically, this can undermine public trust in those vertical interventions as well. So this creates a challenge for a communications program. As a communications program, can you address this root cause having to do with international funding? And I don’t have an answer to this question, but I think it’s a huge one and an important one, and one that those of us who work in this space need to be thinking about and working towards addressing. So we have one more example here of how this dynamic may play out.
And this is something called demand refusals. So many local communities have become quite sophisticated about the polio eradication initiative and the politics around it. So in Pakistan, some communities have started rejecting polio vaccine, which they know that international agencies and their government want them to accept, as a way of drawing attention to other needs. So this is an interesting situation where they’re not actually concerned about the polio vaccine itself. They’re not worried about it. They are confident that it prevents polio, but because they have so many other needs, as a way of drawing attention to those needs, they’ve been refusing polio vaccine.
So one example is the situation in Bannu which is an area on the Pakistan side of the Pakistan, Afghanistan border, and which had 23 cases of polio in 2019. So the Bannu Chamber of Commerce and Industry actually organized business leaders and people across the city to boycott the polio campaign. This resulted in thousands of refusals. And in this case, the demands of the Chamber of Commerce were actually a reduction in taxes. So here’s what the independent monitoring board for polio eradication had to say about it. They say, the spokesman for the Chamber of Commerce and Industry said it was the only way to get the government to listen.
He also said he has no doubts about the effectiveness of the vaccine, is aware of the dangers of creating a gap in herd immunity that the full coverage of the vaccine offers, but that he and members of his community felt they had no choice. So this is one example of a number of demand refusals. Other ones have been communities demanding electricity, sanitation, other issues. And the issue here is that there’s so much government and international focus on polio, and so little government and international focus on these other issues, that communities have been refusing polio vaccine as a way of trying to leverage support for these other issues that they feel are more important.
And again, this is a question I don’t have an answer to, but for you to think about what would you do in this situation. If you were a polio communicator, how would you try to address some of these challenges? And again, this is going to take more than a mass media campaign. It’s about listening to people and their needs, building trust over the long term, and thinking about health services broadly. So the takeaway here is that relentless focus on a single disease can end up becoming problematic for the vertical program itself in the case of polio. And this is not to say that vertical programs are inherently problematic.
In areas where polio eradication activities have been less intense, these sorts of issues generally have not arisen. But a mismatch between the emphasis on polio vaccination and other services can drive distrust. So I’ve got a couple of questions for you to sort of ponder, and we’ll discuss what’s been tried in the next section. But these are some things for you to think about in the meantime. What kind of health communication strategies might work in a context where people are dissatisfied with priorities and the way that services are being provided? And second, what could polio staff do when dissatisfaction with their projects stems from issues beyond the polio program?

Svea Closser, MPH, PhD Bloomberg School of Public Health, Johns Hopkins University, USA

Listening to communities and their needs and building trust over time, and providing broader health services instead of promoting singular focus on a vertical program are a few key considerations in decreasing hesitancy and refusals towards the program, as we saw in the two examples from the DRC and Nigeria.

Please review the reading What led to the Nigerian boycott of the polio vaccination campaign?

Now, reflecting on the reading and the previous video, consider these questions:

What kind of health communication strategies might work in a context where people are dissatisfied with priorities and the way that services are being provided?

What could polio staff do when dissatisfaction with their project stemmed from issues beyond the polio program?

Please take a moment to share your thoughts in the discussion.

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