tag:theconversation.com,2011:/institutions/university-of-global-health-equity-3205/articlesThe University of Global Health Equity2022-02-08T14:12:20Ztag:theconversation.com,2011:article/1756742022-02-08T14:12:20Z2022-02-08T14:12:20ZHealth, happiness and income inequity: fresh insights from an African perspective<figure><img src="https://images.theconversation.com/files/443704/original/file-20220201-15324-14v12n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kigali, Rwanda: In Rwanda there are various positions and groups that are responsible for aspects of governance and decision-making.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Problems with some forms of inequity are easier to understand than others. Unequal access to healthcare or food, for example, is clearly bad for everyone’s wellbeing, contentment and productivity.</p>
<p>The problem with some other forms of inequity, however, is less clear. For instance, not every individual can have the same “opportunities”. </p>
<p>My colleagues and I were intrigued by the apparent link between income inequity and health. In particular, we were puzzled by the <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/inequality-an-underacknowledged-source-of-mental-illness-and-distress/985DE9F19CEA4165BE1E85A022BEFDFB">assertion</a> that income inequity was robustly associated with wellbeing and stress. Why would knowing that a small proportion of people have preposterously large incomes necessarily affect someone’s wellbeing? We wanted answers to the questions of why income inequity is a problem and why it has been so difficult to resolve. </p>
<p>To answer these questions, we undertook an extensive search of the published literature. We <a href="https://www.researchgate.net/publication/350623343_Deconstructing_Health_Inequity_A_Perceptual_Control_Theory_Perspective">studied</a> the publications of leading authorities in the field of health inequity and examined the sources they had referenced.</p>
<p>One of our initial discoveries was the caveats that apply to the apparent link between income inequity and people’s health and happiness. For example, the research underpinning this link applies only to more affluent countries. In poorer countries, economic development is of greater importance for wellbeing than the gap between those with the most money and those with the least.</p>
<p>We didn’t start our investigation to discover where income inequity might have the greatest relevance. But our findings did suggest income inequity might have limited relevance in African settings. What might, perhaps, be more important for wellbeing is the ability to contribute to decisions about how to live in a social group. Therefore, political, economic, and governance structures might be more important than income inequity.</p>
<h2>Investigating inequity</h2>
<p>We <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837404/">came across</a> frequent references to concepts like self-determination, freedom, capability, agency, and opportunity. Michael Marmot, a professor of epidemiology and public health, is a highly regarded authority in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837404/">this area</a>. For example, he writes about the freedom to be and to do. He suggests that it is not so much how much money you have “but what you can do with what you have” that is important for your health. Joseph Stiglitz, the American economist and public policy analyst, <a href="https://www.vanityfair.com/news/2011/05/top-one-percent-201105">proposes</a> that burgeoning inequity is one side of a coin with shrinking opportunity on the other side. </p>
<p>A recent <a href="https://www.penguin.co.uk/books/314/314162/the-dawn-of-everything/9780241402429.html">review</a> of the historical origins of inequity suggested that the fundamental issue is not how equitably people are able to access material resources. Rather, it is how equitable the capacity is to contribute to decisions about how to live together.</p>
<p>For us, all these ideas could be captured and accommodated by the fundamental mechanism of individual control of key priorities for living. The process of control is the defining feature of life. It refers to keeping a balance at all levels of functioning for all living things. Control explains why the capacity to contribute to decisions about how to live and live together has always mattered so much to people.</p>
<p>Through our efforts to understand inequity more clearly, we arrived at the position that inequity in and of itself is not a problem. Compromised control is the problem because it interferes with people’s ability to live as they would prefer. </p>
<p>Stiglitz, for example, maintains that inequity in the US exists because <a href="https://www.vanityfair.com/news/2011/05/top-one-percent-201105">the top 1%</a> (in terms of income) want it to. He suggests that the ultra rich are able to directly influence political decision-making, including systems of taxation, so that their fortunes are protected. He reminds us that the fate of the top 1% is inextricably linked to the fate of the remaining 99%. But the very rich often ignore this fact, to their ultimate peril.</p>
<h2>Relevance to African countries</h2>
<p>Inequity, therefore, and especially income inequity, might have limited relevance in African settings. The concept of control, however, encompassing the ability to contribute to decisions about how one can live harmoniously and productively in a social group, may have much greater relevance and application.</p>
<p>Healthcare services could do much more to adapt treatments and interventions to local contexts. For wellbeing, this might involve developing programmes based on the prevailing culture and belief systems rather than imposing, for example, western biomedical ideas of psychological illness. Rwandan scholar Jean Pierre Ndagijimana <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/ajcp.12571">describes</a> the development of a programme of psychological healing in Rwanda that was based on local concepts like <em>kongera kwiyubaka</em> and <em>kwigira</em> (rebuilding ourselves again).</p>
<p>Governance structures that provide opportunities for people at a local level to contribute to decision-making would also enhance people’s abilities to control important factors in their life. Rwanda, for example, is organised according to provinces, districts, sectors, cells and villages. At each level are various positions and groups that are responsible for different aspects of governance and decision-making. This move to more <a href="https://www.gov.rw/government/administrative-structure">decentralised forms of government</a> commenced in 2001 and <a href="https://www.gov.rw/government/administrative-structure#:%7E:text=The%20country%20is%20divided%20into%20four%20Provinces%20and%20the%20City,are%20divided%20into%2014837%20villages.">is reported</a> to have increased citizen participation in local decision-making as well as greater equity in resource allocation and services.</p>
<h2>How things might be different</h2>
<p>Greater attention to control could be helpful in a general sense. Corruption is often identified as a problem in government, organisations and industries. Corruption might be considered as nothing more than people in positions of authority using that authority at their own discretion to advantage some people while disadvantaging others. A CEO, for example, might create positions in an organisation for family members and remove people who disagree.</p>
<p>Inequity, as a concept, has not been a <a href="https://www.penguin.co.uk/books/314/314162/the-dawn-of-everything/9780241402429.html">topic</a> of interest and investigation for all time and across all people. Control is as important as life itself. The important lesson from our very earliest beginnings is that societal structures and institutions generally, as well as entities such as healthcare systems, must be organised so that the few do not determine the fates of the many. </p>
<p>The sustainability of social living depends on being able to find ways for all members of a community, society, nation, and indeed the planet, to live lives of their own design without preventing others from doing the same.</p><img src="https://counter.theconversation.com/content/175674/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy A. Carey works for the University of Global Heatlh Equity. </span></em></p>Governance structures that provide opportunities for people to contribute to decision-making would also enhance people’s abilities to control important factors in their life.Timothy A. Carey, Director: Institute of Global Health Equity Research, Andrew Weiss Chair of Research in Global Health, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1715032021-11-14T06:56:02Z2021-11-14T06:56:02ZThe number that matters in the COVID pandemic is a relative one: vaccine inequity<figure><img src="https://images.theconversation.com/files/431525/original/file-20211111-13-75raot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When some stockpile valuable resources to the detriment of others, everyone loses</span> <span class="attribution"><span class="source">Emmanuel Osodi/Majority World/Universal Images Group via Getty Images</span></span></figcaption></figure><p>Numbers are extremely useful for succinctly conveying important information. Of course, all quantification, including statistics, has its limitations but it also has valuable advantages. The key is to make sure that the most relevant numbers are being used and prioritised appropriately. </p>
<p>It is straightforward to obtain statistics about the percentage of people vaccinated in any particular country or region as well as the number of deaths or tests there have been. US president Joe Biden reports being proud at having donated <a href="https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/09/09/remarks-by-president-biden-on-fighting-the-covid-19-pandemic-3/">nearly 140 million vaccines to over 90 countries</a>.</p>
<p>What matters most, though, is not the absolute number of vaccines that have been distributed or how countries are positioned on the global vaccination league ladder. It is the number of vaccines relative to need that have been made available and the number of vaccinations in the most vaccinated country relative to the number of vaccinations in the least vaccinated country. </p>
<p>The COVID war will be won or lost on the equity battlefield. And equity is a relative, not an absolute, matter. </p>
<p>Income inequity is a great illustration of the importance of relativity when inequity is being considered. Income inequity, for example, is not about the total wealth of a nation, but how that wealth is distributed. It is about the gap between those with the most and those with the least. The <a href="https://corporatefinanceinstitute.com/resources/knowledge/economics/gini-coefficient/">Gini coefficient</a> is a metric from economics that represents the income inequality in a nation or region. Gini ranges from 0 (perfect equality; everyone has the same income) to 1 (perfect inequality; one person has all the income). Like any metric, the Gini coefficient <a href="https://www.palgrave.com/gp/book/9783030680527">has its limitations</a>. But it’s able to provide some information about the haves and the have-nots with regard to income in a particular jurisdiction.</p>
<p>As with income inequity, it is the gap that needs to be the primary focus of the COVID war. It is of very little comfort, for example, that Canada has a <a href="https://ourworldindata.org/covid-cases">total vaccination rate</a> per 100 people of 155.67 while Tanzania has a rate of 1.63. Nobody will be safe from COVID while <a href="https://www.unicef.org/coronavirus/donate-doses-now?gclid=Cj0KCQiA-K2MBhC-ARIsAMtLKRtxs1u0LPmay1ADdStuqgsXyKT1qm0E4NWzqeTig_0EldoDvIGWxSQaAs4cEALw_wcB">vaccine inequity gaps</a> of this magnitude exist. Where vaccine rates are low, the virus can continue to spread and proliferate. This increases the risk of more deadly and contagious variants appearing.</p>
<p>This is why the world needs something like a Gini coefficient to measure vaccine inequity. It can help identify the best places to direct efforts for the most prudent use of limited resources to ensure the global community has the vaccination coverage it needs to control COVID. </p>
<h2>Illustrating the gap</h2>
<p>In September 2021, I collected data on the <a href="https://ourworldindata.org/covid-cases">total vaccinations per 100 people</a> for <a href="https://www.worldometers.info/geography/how-many-countries-in-europe/#:%7E:text=There%20are%2044%20countries%20in,according%20to%20the%20United%20Nations.">10 of the 44 countries of Europe</a> and <a href="https://www.worldometers.info/geography/how-many-countries-in-africa/">12 of the 54 countries of Africa</a>. I wanted to illustrate the value that a coefficient quantifying the gap might bring to our global deliberations. The countries were selected randomly. The slight difference in the number of countries selected was to keep the proportions approximately the same.</p>
<p>The data were illuminating and instructive. </p>
<p>The range for the European countries was from 32.49 total vaccinations per 100 people (Bosnia and Herzegovina) to 149.46 total vaccinations per 100 people (Spain). The median for these European representatives was 78.585 total vaccinations per 100 people. </p>
<p>For Africa, the range was from 0.57 total vaccinations per 100 people (Tanzania) to 150.04 total vaccinations per 100 people (Seychelles). The Seychelles is a spectacular outlier. The next highest African country had 26.34 total vaccinations per 100 people (Equatorial Guinea). </p>
<p>There are, no doubt, more sophisticated ways of quantifying a global vaccine disparity with a single metric. But it is a metric such as this that needs to be front and centre of the COVID battle strategy. Other metrics will then be helpful in a supplementary way, to identify where resources need to be concentrated to shift the gap metric in the direction we want.</p>
<p>The <a href="https://www.euro.who.int/en/health-topics/health-emergencies/pages/news/news/2021/05/q-and-a-covid-19-variants-and-what-they-mean-for-countries-and-individuals">effectiveness of vaccination</a> as a public health strategy will continue to be compromised while large numbers of the global community remain unvaccinated. The WHO strongly recommends that people “<a href="https://www.euro.who.int/en/health-topics/health-emergencies/pages/news/news/2021/05/q-and-a-covid-19-variants-and-what-they-mean-for-countries-and-individuals">take up their offer of a vaccine when their turn comes</a>”. Unfortunately, too few people’s turns are coming up fast enough. A ponderous approach to organising and arranging vaccine distribution is no match for SARS-CoV-2 and its rapidly expanding band of variants.</p>
<p>So, while the citizens of countries like Spain and the Seychelles might feel some comfort about the vaccination rates in their countries, it is a comfort of exquisite fragility while the current enormous disparity exists. A gap metric that represents the disparity might provide a more sobering message that could add extra incentive to overcome global inequity inertia.</p>
<p>A metric such as this might not be particularly complex. In <a href="https://psycnet.apa.org/record/2013-45032-006">previous research</a>, I created an “efficiency coefficient” in psychotherapy research to complement the voluminous effectiveness metrification that occurs. The efficiency coefficient was simply the ratio of effect size to average number of sessions. In principle, it should be relatively straightforward to create an analogue of the Gini Coefficient that quantifies vaccine inequity from 0 (every region or country has their entire eligible population vaccinated) to 1 (1 region or country has their entire eligible population vaccinated and every other country or region has none of their eligible population vaccinated). </p>
<p>The most important war might not be with COVID at all. Perhaps the greatest conflict is coming to terms with the fact that when some stockpile valuable resources to the detriment of others, everyone loses. The number to monitor is the vaccine inequity gap.</p><img src="https://counter.theconversation.com/content/171503/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy A. Carey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The effectiveness of vaccination as a public health strategy will continue to be compromised while large numbers of the global community remain unvaccinated.Timothy A. Carey, Director: Institute of Global Health Equity Research, Andrew Weiss Chair of Research in Global Health, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1686152021-09-24T11:24:55Z2021-09-24T11:24:55ZA granular look at UK’s COVID-19 ‘red list’ shows why it’s deeply flawed<figure><img src="https://images.theconversation.com/files/423089/original/file-20210924-19-1h38l1q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over 40% of the countries on the UK's COVID-19 'red list' are in sub-Sahara Africa.</span> <span class="attribution"><span class="source">Photo by Tolga Akmen/AFP via Getty Images</span></span></figcaption></figure><p>Earlier this year the UK introduced a “traffic light” system in yet another attempt to contain and mitigate the effects of COVID-19. The <a href="https://www.gov.uk/guidance/red-amber-and-green-list-rules-for-entering-england#amber-list-rules">system</a> assigned the status of either red, amber, or green to other countries with each colour indicating different rules for a range of things including terms of travel and quarantine requirements. </p>
<p>In mid-September the UK government announced a change to the three lists: the amber and green colours were replaced with one “<a href="https://www.timeout.com/news/travellers-from-these-red-listcountries-are-now-banned-from-the-uk-091921">OK to travel</a>” category. The red list remains in place. The changes will take effect from <a href="https://www.gov.uk/guidance/red-amber-and-green-list-rules-for-entering-england#new-rules">4 October</a>.</p>
<p>Attempting to determine the justification for the lists and accurate details about them is less than straightforward. The rules for which countries are in or out is far from transparent making it difficult to find any justification for why a country is placed on the red list and, perhaps more importantly, how they get off it.</p>
<p>Of the <a href="https://www.gov.uk/guidance/red-amber-and-green-list-rules-for-entering-england#red-list">54 countries</a> on the red list 22 (approximately 41%) are from sub-Saharan Africa. Put another way, of the <a href="https://openknowledge.worldbank.org/pages/focus-sub-saharan-africa">48 countries making up the sub-Saharan region</a>, 21 (approximately 44%) are on the UK’s red list. </p>
<p><a href="https://www.independent.co.uk/travel/news-and-advice/travel-restrictions-covid-red-list-update-b1921515.html">Reports</a> suggest that the UK Government’s justification for placing a country on the red list include: known variants of concern; known high-risk variants that are under investigation; and very high in-country or territory prevalence of COVID-19.</p>
<p>These justifications are difficult to understand on a number of levels. The revised rules reported on the <a href="https://www.gov.uk/guidance/red-amber-and-green-list-rules-for-entering-england#new-rules">UK government’s website</a> are similarly opaque. </p>
<p>Just take the issue of variants. An important feature about viruses like COVID-19 is that mutations are a <a href="https://www.euro.who.int/en/health-topics/health-emergencies/pages/news/news/2021/05/q-and-a-covid-19-variants-and-what-they-mean-for-countries-and-individuals">natural phenomenon</a>. Some mutations present additional risks but many are <a href="https://www.euro.who.int/en/health-topics/health-emergencies/pages/news/news/2021/05/q-and-a-covid-19-variants-and-what-they-mean-for-countries-and-individuals">inconsequential </a>. And, of course, knowledge about the variants present in any country at any particular time depends entirely on the accuracy and extent of testing taking place.</p>
<p>This is just one reason why the red list has kicked up a storm, with some recommending that it be “<a href="https://www.independent.co.uk/travel/news-and-advice/travel-restrictions-covid-red-list-update-b1921515.html">scrapped in its entirety</a>”. In South Africa <a href="https://www.businesslive.co.za/bd/national/health/2021-09-21-sa-scientists-dispute-uks-red-list-claims/">scientists</a> have been critical of the reasons cited as justification for retaining their country on the red list.</p>
<p>When the UK’s red list is considered at perhaps a more granular level, the difficulties become immediately apparent. Two scenarios point to the flawed logic being applied.</p>
<h2>Sudan versus South Sudan</h2>
<p>Sudan is on the red list whereas South Sudan is not. </p>
<p>Yet the numbers available about COVID-19 in the two countries point to this being a ridiculous call.</p>
<p>Current estimates are that Sudan has <a href="https://ourworldindata.org/covid-cases">a rate of daily new confirmed cases per million</a> of 0.23. South Sudan’s rate is higher, at 1.18. On top of this Sudan’s rate of total vaccinations per 100 is 3.34, South Sudan’s is much lower at 0.84.</p>
<p>Sudan has a rate of total deaths per one million of 64.15 while South Sudan’s rate is 10.36. </p>
<p>At the end of July <a href="https://radiotamazuj.org/en/news/article/covid-19-south-sudan-witnesses-resurgence-confirms-delta-variant">South Sudan had confirmed the presence of the Delta variant</a> while the <a href="https://www.dabangasudan.org/en/all-news/article/covid-19-spread-of-delta-variant-in-sudan-not-confirmed">spread of the Delta variant in Sudan</a> had not been confirmed.</p>
<p>One may well question what these data tell us about the two countries. It is very hard to make firm conclusions in the absence of information about the health systems and other important factors in the two countries. Comparisons become difficult and somewhat arbitrary. </p>
<p>This is precisely the difficulty with the red list. </p>
<p>Is it a case of cherry-picking the data? At the very least it indicates an opaqueness to decision-making that should be unacceptable in an era of rigorous scientific thinking and evidence-based policy making. When difficulties arise, we need to raise, rather than lower, the bar on our standards of what counts as credible evidence. </p>
<h2>Barbados versus Rwanda</h2>
<p>The rules around the red list and vaccination status is equally baffling and difficult to fathom. </p>
<p>The UK Government website states that from 4am on 4 October, <a href="https://www.gov.uk/guidance/red-amber-and-green-list-rules-for-entering-england#red-list">you will qualify as fully vaccinated according to two criteria</a>. The first specifies an approved vaccination programme from a small number of countries. The second stipulates a full course of one of four named vaccines from a “relevant public health body” in 18 different countries. None are in Africa. </p>
<p>Also, from that date</p>
<blockquote>
<p>if you have been in a red list country in the last 10 days, you will only be allowed to enter the UK if you are a British or Irish national or you have residence rights in the UK.</p>
</blockquote>
<p>To illustrate how ridiculous this is I have mapped out a scenario.</p>
<p>I am an Australian academic currently working in Rwanda. I have had both doses of the Pfizer vaccine and have had numerous COVID-19 tests all with negative results. Neither I nor any member of my family have ever tested positive for COVID-19. I received my Pfizer COVID-19 vaccinations in Rwanda, a country that acted swiftly and decisively with clear and transparent leadership from the earliest indications of the monumental significance of the virus. </p>
<p>Despite all this, I will be unable to visit the UK under any conditions. </p>
<p>Suppose I have a colleague from the UK who, prior to relocating to Rwanda, received her two Moderna vaccinations in Barbados – one of the countries named with an approved vaccination programme – and has been living in Rwanda for six months. After she had been in Rwanda for two months she, hypothetically, tested positive for COVID-19 even though she was asymptomatic. From 4am on 4 October she would be able to return to the UK according to certain rules such as <a href="https://www.gov.uk/guidance/red-amber-and-green-list-rules-for-entering-england#red-list">a pre-departure test and a period of quarantine</a> once she arrives.</p>
<p>It is unfathomable to me how this can be achieving anything other than an exacerbation of existing inequities. What possible difference can it make where I had my vaccinations? Is there some reason that being vaccinated in Rwanda or South Africa is inferior to being vaccinated in Barbados (with <a href="https://ourworldindata.org/covid-cases">360.98 daily new confirmed cases per million</a> or Malaysia with <a href="https://ourworldindata.org/covid-cases">488.11 daily new confirmed cases per million</a>? </p>
<p>In fact the World Health Organisation recently <a href="https://www.newtimes.co.rw/news/who-commends-rwandas-covid-19-vaccination-drive">commended Rwanda’s vaccination drive</a>. Yet it remains on the UK’s red list and Rwanda is <a href="https://www.gov.uk/guidance/red-amber-and-green-list-rules-for-entering-england#red-list">not listed</a> as a country with an approved vaccination programme. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-rwanda-is-managing-its-covid-19-vaccination-rollout-plans-158987">How Rwanda is managing its COVID-19 vaccination rollout plans</a>
</strong>
</em>
</p>
<hr>
<p>More fancy footwork with numbers perhaps? Or simply skewed thinking.</p>
<h2>Equity in global health</h2>
<p><a href="https://www.euro.who.int/en/health-topics/health-emergencies/pages/news/news/2021/05/q-and-a-covid-19-variants-and-what-they-mean-for-countries-and-individuals">The World Health Organisation</a> is clear that</p>
<blockquote>
<p>vaccination will not bring an end to this pandemic until it is distributed to everyone around the world. </p>
</blockquote>
<p>Yet some countries, predominantly high-income ones, are stock piling far more vaccines than they need and providing booster shots to people who don’t require them.</p>
<p>COVID-19 is providing us with opportunities to learn a great many things about health and health systems. But perhaps it’s most valuable lesson is the inescapable importance of equity to the global community. That lesson is ignored to the peril of us all.</p>
<p>Maybe rather than focusing on a red list country club with unclear and questionable criteria, we should create a red list of countries that are actively creating vaccine distribution inequities.</p><img src="https://counter.theconversation.com/content/168615/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy A. Carey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When the UK’s red list is considered at a more granular level, the difficulties become immediately apparent.Timothy A. Carey, Director: Institute of Global Health Equity Research, Andrew Weiss Chair of Research in Global Health, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1684012021-09-23T14:08:56Z2021-09-23T14:08:56ZWhat the objections to COVID-19 control measures tell us about personal freedom<figure><img src="https://images.theconversation.com/files/422657/original/file-20210922-17-1s3v3sr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Civilians protesting against COVID-19 vaccine mandates in Cape Town, South Africa.</span> <span class="attribution"><span class="source">Brenton Geach/Gallo Images via Getty Images</span></span></figcaption></figure><p>As the protracted global battle with SARS-CoV-2 continues to rage, objections to the measures being taken to combat the virus are increasing. <a href="https://www.voanews.com/a/covid-19-pandemic_thousands-around-globe-protest-covid-19-shots-lockdowns/6208675.html">Protests</a> have been reported in countries such as the US, the <a href="https://www.theguardian.com/world/live/2021/sep/18/coronavirus-live-news-holiday-bookings-expected-to-surge-after-england-travel-rules-change-clashes-at-melbourne-protests">UK</a>, <a href="https://www.reuters.com/world/asia-pacific/locked-down-melbourne-braces-more-protests-covid-19-cases-rise-2021-09-22/">Australia</a>, Thailand, South Africa, France, Italy, and Greece. In some instances, the protests have become violent resulting in injuries and arrests.</p>
<p>The core of the objections, whether they are about vaccinations, lockdowns, social distancing, or mask wearing, seems to concern an apparent erosion of personal liberty. Liberty, or freedom, has been fiercely pursued and protected throughout history. Some of the greatest accomplishments in social living have been realised through the introduction of policies and laws that provided freedoms to those who were previously marginalised and persecuted. Efforts to address colonialism, racism, and inequity are relevant examples. To be sure, there is still a long way to go but progress, however slow and punctuated it may be, is being made.</p>
<p>SARS-Cov-2’s unrelenting assault on our health status and systems could be another opportunity to leap forward in our understanding of liberty and social living. Advancing the freedom of all might be accelerated if the relativity of freedom was more readily acknowledged and explicitly discussed. </p>
<p>Freedom, in its simplest terms, is being able to do what you want. The key to freedom, then, is about what you want, what I want, and what we all want. It is about <a href="https://www.australianacademicpress.com.au/books/details/284/Controlling_People_The_Paradoxical_Nature_of_Being_Human">being in control</a>. It is about pursuing the goals that are important to us. Control is concerned with agency and unsurprisingly, both agency and freedom have been identified as important to health. Health, can in fact, be understood as a state of <a href="https://www.palgrave.com/gp/book/9783030680527">being in control</a>.</p>
<h2>Limiting freedom</h2>
<p>The relativity of freedom is unavoidably inevitable. If I am paid a sufficient amount of money, I am free to save up to buy a house. Wanting to buy a house, however, necessarily impacts on my freedom to spend money on other things. If I want to pursue part-time study to get a better job, then my freedom with regard to how I spend my leisure time is immediately curtailed.</p>
<p>People, then, limit their own freedom by the goals they have, but their goals can also limit other people’s freedom. When slave owners had the freedom to buy and sell people as slaves, they were undoubtedly doing what they wanted but they were also interfering monstrously and deplorably with the freedom of the people cast as slaves. </p>
<p>More recently some jurisdictions have <a href="https://www.cdc.gov/hiv/policies/law/states/exposure.html">determined</a> that people do not have the freedom to intentionally transmit HIV through unprotected sex. Similarly, a person does not have the unrestrained freedom to drive a car through a busy shopping mall and annihilate the freedom of shoppers.</p>
<p>The daily <a href="https://www.aljazeera.com/news/2021/9/18/hundreds-arrested-australia-anti-covid-lockdown-protests">news</a> is replete with <a href="https://www.bbc.com/news/uk-england-london-57560664">examples</a> of people having their freedom removed because of the way they interfered with other people’s freedom. Freedom’s relativity is inherently entwined with our nature to be in control. Fundamentally we are <a href="https://www.amazon.com/Making-Sense-Behavior-Meaning-Control/dp/0964712156">driven to control</a> our circumstances and conditions. During our controlling, however, from time to time we will, either inadvertently or by design, thwart the controlling of others. It is easy to appreciate that the anger of the COVID-19 protesters arises from the curbing of their ability to control where they go, when they go, and how they go there.</p>
<p>It is part of the paradox of freedom that curtailing the freedom of some can have the effect of <a href="https://www.palgrave.com/gp/book/9783030680527">increasing the freedom of many</a>. The great American medical physicist William T. Powers suggested that </p>
<blockquote>
<p>the childhood of the human race is far from over. We have a long way to go before most people will understand that what they do for others is just as important to their wellbeing as what they do for themselves.</p>
</blockquote>
<p>Joseph Stiglitz, the Nobel prize winning economist, applies the same thinking to the inequity in wealth distribution. He <a href="https://www.vanityfair.com/news/2011/05/top-one-percent-201105">points out</a> that increasing inequity is the flipside of shrinking opportunity. Shrinking opportunity is nothing more than a constriction of the ability to control. He reminds those who are at the top 1% of the money pile that their fates are interwoven with the fates of the remaining 99%. This fact prompts him to suggest that “looking out for the other guy isn’t just good for the soul – it’s good for business”. </p>
<h2>Interwoven fates</h2>
<p>In a cruel twist of fate that might actually reveal the secret to successful social living, we have our greatest freedom when we protect <a href="https://www.australianacademicpress.com.au/books/details/284/Controlling_People_The_Paradoxical_Nature_of_Being_Human">the freedom of others</a>. Safeguarding our own freedom as a priority will lead to an endless round of pushback as others seek to do the same. As we increasingly promote the freedom of others, particularly the marginalised, vulnerable, and oppressed, we can begin to relax a little and enjoy the more equitable, fairer, and socially just world we are creating.</p>
<p>Freedom is never absolute. Some freedoms are always enjoyed at the expense of other freedoms. We will never be free of COVID-19 until we are all free. Does that mean some other freedoms will, from time to time, be suppressed? Undoubtedly. Necessarily. And the foregoing of those freedoms helps the freedom to live in a healthy, connected, and contented social environment to flourish.</p><img src="https://counter.theconversation.com/content/168401/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy A. Carey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The core of the objections, whether they are about vaccinations, lockdowns, social distancing, or mask wearing, seems to concern an apparent erosion of personal liberty.Timothy A. Carey, Director: Institute of Global Health Equity Research, Andrew Weiss Chair of Research in Global Health, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1589872021-04-19T15:56:40Z2021-04-19T15:56:40ZHow Rwanda is managing its COVID-19 vaccination rollout plans<figure><img src="https://images.theconversation.com/files/395206/original/file-20210415-18-1ruxocx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A refugee receives his first dose of coronavirus vaccine in Kigali, Rwanda. </span> <span class="attribution"><span class="source">Habimana Thierry/Anadolu Agency via Getty Images</span></span></figcaption></figure><p><em>It’s been over a year since COVID-19 was <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020">declared</a> a pandemic. In an amazing feat of science and technology, a number of safe and effective <a href="https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines">vaccine candidates</a> have been developed. Most developed countries are well-advanced in rolling out vaccinations. The process is much slower in developing countries. In Rwanda, the government set a target of vaccinating 60% of the population – of nearly <a href="https://www.worldometers.info/world-population/rwanda-population/">13 million</a> – by the end of 2022. To unpack Rwanda’s rollout strategy Ina Skosana from The Conversation Africa spoke to public health expert Professor Agnes Binagwaho.</em></p>
<hr>
<h2>What is the country’s COVID-19 vaccination strategy?</h2>
<p><a href="https://www.gavi.org/vaccineswork/rolling-out-covid-19-vaccines-rwanda#:%7E:text=The%20COVID%2D19%20vaccination%20campaign,by%20the%20end%20of%202022.%E2%80%9D">Rwanda’s strategy</a> was developed based on scientific evidence and was rooted in the ideals of equity. This is much like Rwanda’s overall COVID-19 preparedness and response <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908927/">efforts</a>. </p>
<p>The Ministry of Health defined a clear vaccination plan as soon as an agreement was finalised with <a href="https://www.who.int/initiatives/act-accelerator/covax">COVAX</a>, a global initiative aimed at equitable access to COVID-19 vaccines, and well before the vaccines from COVAX were delivered. </p>
<p>The plan had a priority list to ensure that essential workers and people most at risk of infection and COVID-19-related death would receive the vaccine first. The list of 3 million included frontline healthcare workers, the elderly, individuals with underlying conditions, and people living in crowded settings such as refugees and prison populations. Other essential workers such as teachers and women and men in uniform were also included. </p>
<p>Individuals were vaccinated across the country starting with healthcare workers, including the nearly 60,000 community health workers. </p>
<p>Weeks before the vaccines arrived in the country, the Ministry of Health prepared its storage and distribution capacity. In addition to preparing regular refrigerators used for other vaccines, Rwanda purchased five ultra-low refrigerators to store the Pfizer vaccine at -70 degrees Celsius.</p>
<p>This early logistical planning meant that Rwanda had the capacity to store 5 million doses before the vaccines arrived. The country also purchased refrigerated vehicles to ensure that all corners of the country could be reached. </p>
<p>Everyone in government and implementing partner institutions, such as UNICEF and the World Health Organisation (WHO), understood their role and were ready to start the campaign when the vaccines landed. To ensure equitable access to vaccines and remove any geographical barriers, Rwanda set up vaccination sites at health centres (one in each sector) and district hospitals. Healthcare workers in these sites were also trained before the arrival of the vaccines.</p>
<p>Rwanda put a lot of effort into fostering demand for the vaccines. The health ministry collaborated with civil society, faith-based organisations, local authorities and young volunteers to disseminate a one-page <a href="https://rbc.gov.rw/fileadmin/user_upload/annoucement/Factsheet%20covid%2019%20vaccine%20Kinya.pdf">fact sheet</a> with information on the vaccines. <a href="https://www.youtube.com/watch?v=Hmm6usDRg6w">Radio and TV channels</a> were also used to provide further information on the vaccines, with the Minister of Health and other health sector officials engaging with the public. </p>
<p>Lastly, to target vaccine hesitancy the government set up a toll free number so that people could report side, effects, or share positive stories. </p>
<h2>What is the progress so far?</h2>
<p>Rwanda received the first batch of vaccines in early March from the COVAX initiative: 342,960 Pfizer and AstraZeneca vaccines. Rwanda also received 50,000 donated doses from India on March 5th, 2021. </p>
<p>These were distributed within 48 hours to all district hospitals, which in turn distributed them to all health centres using trucks and military helicopters for hard-to-reach districts. </p>
<p>Within two days Rwanda had started its nationwide vaccination campaign. Vaccines were first administered to frontline healthcare workers as planned. </p>
<p>While both types of vaccines require two doses, Rwanda provided the first dose of AstraZeneca to as many people as possible, with the expectation of receiving more vaccines in time for the second dose. This allowed the country to maximise the number of people who were vaccinated. Rwanda is expecting to receive the second batch of COVID-19 vaccines before the end of April. </p>
<p>As of April 11th, 2021, 348,925 people in Rwanda had received their first dose of vaccines. This is nearly 9% of the 2021 target for vaccinated individuals. </p>
<h2>What are the challenges?</h2>
<p>Equitable distribution of vaccines continues to be a challenge across the world. </p>
<p>It is estimated the many people in low-income countries will have to wait until <a href="https://www.nature.com/articles/d41586-020-03370-6">2023</a> to be vaccinated.</p>
<p>Various factors contribute to this inequity. High-income countries are <a href="https://www.sciencemag.org/news/2021/03/countries-now-scrambling-covid-19-vaccines-may-soon-have-surpluses-donate">hoarding</a> vaccines. Canada, for example, has secured more than 600% of the doses it needs to vaccinate its entire population. Moreover, these same countries are <a href="https://www.msf.org/countries-obstructing-covid-19-patent-waiver-must-allow-negotiations">unwilling to share</a> the vaccine technology. </p>
<p>These factors contribute to delays in getting vaccination programmes off the ground in developing countries. This is stalling the achievement of global herd immunity and preventing a quicker return to a state of normalcy.</p>
<p>In Rwanda, this delay can exacerbate an economy that has been pushed into <a href="https://www.worldbank.org/en/news/press-release/2021/02/08/covid-19-pandemic-pushes-rwanda-into-recession-severely-impacts-human-capital">recession</a> during the pandemic, further affecting the economic well-being of individuals and businesses. </p>
<p>Unless high-income countries share the vaccine technology and decentralise the production of approved vaccines, we will all continue to face the repercussions of the COVID-19 pandemic. </p>
<h2>What needs to happen next?</h2>
<p>To meet its target of vaccinating 60% of the population of nearly <a href="https://www.worldometers.info/world-population/rwanda-population/">13 million</a> by the end of 2022, Rwanda will need to procure more vaccines. </p>
<p>The country hopes to achieve this through international deals, through the African Vaccine Acquisition Task Team of the African Union as well as through the COVAX initiative. </p>
<p>Rwanda is closely following the evidence emerging about the safety of various vaccines and will continue to review the data regularly to ensure that the vaccines administered in the country are safe and effective.</p>
<p>The country will also continue to strictly enforce COVID-19 regulations such as mask wearing and social distancing given the limited supply of vaccines available in the country. These measures will also ensure the protection of the country in case of delays in vaccine delivery.</p><img src="https://counter.theconversation.com/content/158987/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Binagwaho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Due to early logistical planning, Rwanda had the capacity to store 5 million doses before the vaccines arrived.Agnes Binagwaho, Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1488452020-10-28T14:26:54Z2020-10-28T14:26:54ZCOVID-19: A global survey shows worrying signs of vaccine hesitancy<figure><img src="https://images.theconversation.com/files/366084/original/file-20201028-13-1h5578x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The increasingly well-coordinated global anti-vaccine movement has repurposed itself to challenge the very reality of COVID-19.</span> <span class="attribution"><span class="source">Hasan Esen/Anadolu Agency via Getty Images</span></span></figcaption></figure><p>It has been nine months since the World Health Organisation (WHO) declared the outbreak of COVID-19, caused by the SARS-CoV-2 virus, a <a href="https://extranet.who.int/sph/covid-19-public-health-emergency-international-concern-pheic-under-ihr">“public health emergency of international concern”</a>. Since then, more than <a href="https://www.worldometers.info/coronavirus/">44 million cases</a> have been recorded and <a href="https://www.worldometers.info/coronavirus/">over one million lives</a> lost. Economic costs measure in trillions of dollars. Global recovery will take years.</p>
<p>A safe, effective COVID-19 vaccine is expected to be developed in record time and may be approved for production, distribution and acceptance some time in 2021. Public health experts say that <a href="https://www.nature.com/articles/d41586-020-02944-8">at least 70%</a> of any community must get vaccinated with a COVID-19 vaccine to achieve an acceptable level of immunity to protect its members.</p>
<p>We <a href="https://www.nature.com/articles/s41591-020-1124-9">recently surveyed</a> 13,426 people in 19 countries. We included two of Africa’s most populous and visible nations, Nigeria and South Africa, which are among the most affected by COVID-19 on the continent.</p>
<p>Overall, we found that 71.5% of participants said they would take a “proven safe and effective vaccine” while 14% would refuse it outright. An additional 14% said they would hesitate to take the vaccine. </p>
<p>But that average figure is deceptive. It was raised by favourable responses from two Asian countries that also recorded very high trust in government health recommendations. More than 80% of Chinese respondents and 75% of South Koreans said they would accept a vaccine. South Africans came closer than any other country to the 70% standard, at almost 65%. But only 46.3% of Nigerians said they would do so. This is slightly higher than the results we found in Spain, Sweden, Poland, Brazil and Ecuador.</p>
<h2>Hesitancy</h2>
<p>These vaccine hesitant people are not necessarily vaccine opponents. A large number of them consistently vaccinate their children against numerous childhood diseases. However, it must be noted that the increasingly well-coordinated <a href="https://www.thelancet.com/journals/landig/article/PIIS2589-7500(20)30227-2/fulltext">global anti-vaccine movement</a> has repurposed itself to challenge the very reality of COVID-19 as well as the usefulness of a new vaccine to prevent it. They have leveraged social media platforms to promote these doubts.</p>
<p>We also tried to determine how much trust people would have in a COVID-19 vaccine if their employer recommended it. Just more than three in five (61.4%) of all our respondents said they would do so. The numbers dropped to less than half of South Africans (46%) and Nigerians (44%).</p>
<p>Our data confirms a troubling trend towards vaccine hesitancy that has been found in <a href="https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(19)30092-6/fulltext">other global</a> and <a href="https://www.spotlightnsp.co.za/2020/10/07/what-we-know-about-vaccine-hesitancy-in-south-africa/">national</a> studies. Professor Heidi Larson, a co-author of our paper, and her team at the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31558-0/fulltext">recently reported</a> on trends in vaccine confidence observed across 149 countries between 2015 and 2019. They found that political instability and religious extremism were critical factors in declining vaccine confidence in many of these countries.</p>
<p>Recent political unrest in <a href="https://theconversation.com/livestreaming-lekki-digital-evidence-of-endsars-shooting-in-nigeria-makes-impunity-much-harder-148696">Nigeria</a>, Africa’s most populous country with over <a href="https://theconversation.com/endsars-how-nigeria-can-tap-into-its-youthful-population-148319">200 million people</a>, does not bode well for a successful COVID-19 vaccination campaign there. Only South Africa and Ethiopia have recorded more COVID-19 cases on the continent.</p>
<p>Many public health workers also recall a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831725/">massive boycott against polio vaccination</a> in northern Nigeria. It was caused by a single rumour, and not an adverse event. This boycott led to the years of more polio infections and deaths in <a href="https://theconversation.com/valuable-lessons-from-nigerias-marathon-effort-to-eradicate-polio-124653">Nigeria</a>, and delayed polio eradication from the continent as a whole. </p>
<p>So what must be done to get on track for a successful African vaccination programme against COVID-19?</p>
<h2>Moving forward</h2>
<p>As scientists, we should help health leaders to prepare now with education and dialogue to set appropriate expectations for when a coronavirus vaccine may be available. We need to build vaccine literacy with effective communication and community engagement for acceptance country by country, village by village, taking into account community-specific issues, concerns or misconceptions and working with local religious and civil leaders and influencers.</p>
<p>We also need to help people become more fluent about vaccinations: Are they safe? Will they protect me and my family? Do I need to be vaccinated to be able to work? Will everyone be able to get it? Will vaccination sterilise me or my kids?</p>
<p>And we must be realistic that none of this information and advocacy will truly convince people to accept COVID-19 vaccination, or any other, in the absence of genuine societal trust. Without mutual trust, we may not be able to rebuild economies and return to anything approaching “normal” life.</p>
<p>It would be tragic if we developed, made and distributed safe and effective COVID-19 vaccines and people refused to take them, when health infrastructure and equipment levels cannot stem the pandemic.</p>
<p><em>Two authors of this study, Drs. Ratzan and Larson, are co-leaders of a recently launched global coalition – CONVINCE [COVID-19 New Vaccine Information Communication and Engagement]. This initiative is spearheaded by the CUNY Graduate School of Public Health, the Vaccine Confidence Project of the London School of Hygiene and Tropical Medicine, and Wilton Park, a part of the UK’s Foreign, Commonwealth and Development Office. A number of African public health leaders have already joined it.</em></p><img src="https://counter.theconversation.com/content/148845/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A safe, effective COVID-19 vaccine is expected to be developed in record time and may be approved for production, distribution and acceptance some time in 2021.Scott C. Ratzan, Distinguished Lecturer, CUNY Graduate CenterAgnes Binagwaho, Vice Chancellor, University of Global Health EquityHeidi Larson, Senior Lecturer in Epidemiology & Population Health, London School of Hygiene & Tropical MedicineJeffrey V Lazarus, Associate Research Professor, Barcelona Institute for Global Health (ISGlobal)Kenneth Rabin, Senior Scholar, CUNY Graduate CenterLawrence O. Gostin, University Professor; Founding Linda D. & Timothy J. O’Neill Professor of Global Health Law, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1472222020-10-14T13:24:28Z2020-10-14T13:24:28ZTraining can improve patient and health worker safety in sub-Saharan Africa<figure><img src="https://images.theconversation.com/files/362904/original/file-20201012-19-hj27fy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health providers need to practise in error-proof environments as much as possible.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Medical technology has made great advances. Yet, patients are often harmed while receiving medical care. Globally <a href="https://www.who.int/news-room/fact-sheets/detail/patient-safety#:%7E:text=Globally%2C%20as%20many%20as%204,use%20of%20medicines%20(6).%20%22%22">four out of 10 patients</a> are harmed in primary and outpatient care. Furthermore, <a href="https://www.who.int/news-room/fact-sheets/detail/patient-safety#:%7E:text=Globally%2C%20as%20many%20as%204,use%20of%20medicines%20(6).">15% of total hospital activity and expenditure</a> is a direct result of adverse events or irregularities in healthcare delivery. </p>
<p>Worldwide, there are more than <a href="https://news.un.org/en/story/2019/09/1046552">five avoidable deaths every minute</a> as a result of mistakes made by healthcare providers. These mistakes include incorrect diagnosis, wrong medication, and unsafe surgical procedures. </p>
<p>The most sustainable and cost-effective way to protect patients’ lives is to reduce the causes of human error. Therefore, health providers must strive to practise in a ‘error-free’ environment. In order to achieve this goal, health workers need to be properly trained to reduce adverse outcomes.</p>
<p>When health systems are <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/(SICI)1099-1751(200001/03)15:1%3C61::AID-HPM573%3E3.0.CO;2-4?casa_token=EaRpAV2QlzoAAAAA:L3rTqb334HLrFseCq7CEV6nodVKKZG5tEdf_ZykSrB_sgWzyzQNzv3DpJZG9g0I432CM6hw-lRQi2Cvt">under pressure</a>, so too are the professionals working within them. The safety of patients is intricately linked to the safety of health workers. Health professionals working under conditions that compromise their own health and safety will have difficulties delivering the highest standards of safety and quality care to their patients. </p>
<p>Issues concerning compromised health worker safety have become all too evident during the current pandemic. COVID-19 has put health systems around the world under severe stress. Globally, health systems have been grappling with spikes in patient intake, strained resources, new transmission prevention measures, and the need to rapidly develop solutions for an uncharted and ever-evolving health threat. </p>
<p>Several low-income countries have fared better in the fight against COVID-19 than richer and better-resourced nations. Rwanda, for instance, has made substantial progress against this pandemic despite limited resources. Rwanda has been <a href="https://africa.cgtn.com/2020/08/10/rwandas-progress-in-covid-19-fight-is-down-to-strong-leadership-who-chief/">globally praised</a> for its robust, rapid, and human-centred response. </p>
<p>Rwanda has a network of <a href="https://theconversation.com/rwanda-is-training-health-workers-for-an-interconnected-world-131788">well-supported and frequently re-educated health workers</a>, in addition to strong intersectoral collaborations that <a href="https://www.imf.org/en/News/Articles/2020/08/06/na080620-rwanda-harnesses-technology-to-fight-covid-19-drive-recovery">inspire innovative solutions using minimal resources</a>.</p>
<p>A strong and properly trained health workforce is critical to patient care. Professionals who are trained to critically examine and identify the root cause of risks within different settings are better able to avoid risks and advocate for the systemic changes needed to protect both providers and patients.</p>
<h2>Improved training</h2>
<p>Academic and research institutions bear a responsibility in generating the evidence for patient and health worker safety. This evidence will go on to inform policy, regulations, and standards of practice. Competent use of existing technical resources, such as the <a href="https://www.who.int/patientsafety/safesurgery/checklist/en/">Surgical Safety</a> and <a href="https://www.who.int/patientsafety/implementation/checklists/childbirth/en/">Safe Childbirth</a> checklists, is critical. But these resources should be paired with training that fosters a holistic approach to addressing the social, cultural, and economic reasons health providers struggle to provide safe, quality care. Such an approach will better equip health workers to identify and manage the risk factors that result in adverse healthcare outcomes.</p>
<p>Patient and health worker safety needs to be embedded in all health professional training. Critical and independent thinking, problem solving, communication, teamwork and collaboration, as well as leadership and management may all be dismissed by some traditional medical schools as <a href="https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291">“softer skills”</a>. Yet, these skills have <a href="https://www.ncbi.nlm.nih.gov/books/NBK2637/">a direct impact on patient outcomes</a>. For example, ineffective communication can be linked to medical errors, harm to self, and harm to fellow health workers. The inability to communicate effectively can also limit a provider’s ability to engage with their patients – <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6446473/">an essential part of optimising safety</a>. </p>
<p>Fostering leadership and management skills is critical to patient and health worker safety. Strong leadership earns the trust of those served, resulting in better cooperation in scientific-based guidance. Such outcomes were demonstrated by Rwanda’s <a href="https://www.emersoncollective.com/articles/2020/04/lessons-from-rwanda-for-covid-19/">successful participatory approach</a> to fighting COVID-19. </p>
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Read more:
<a href="https://theconversation.com/how-leadership-matters-in-healthcare-especially-in-a-crisis-141321">How leadership matters in healthcare – especially in a crisis</a>
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<p>Equitable caring for patients can’t be achieved without equity in health education. Yet, there are few training programmes for healthcare professionals in patient safety and healthcare quality in sub-Saharan Africa. </p>
<p>The <a href="http://www.ughe.org">University of Global Health Equity</a>, a global health sciences university based in Rwanda, aims to redress this gap. The Center for Executive Education at UGHE is developing a programme in patient safety and healthcare quality. The goal is to train a community of health care providers, administrators, and policy makers in the skills needed to reduce harmful healthcare outcomes.</p>
<h2>Looking forward</h2>
<p>For sustained improvements in global patient and health worker safety, health organisations need to emphasise a systems approach that starts with professional education. Training the next generation of practitioners and health leaders to examine healthcare critically and holistically can help to ensure that the chain of errors and system failures that place patients and health workers at risk is managed more effectively. </p>
<p>The current pandemic has taught us several lessons. The importance of the health and wellbeing of the healthcare workforce is a lesson that can’t be underestimated. Without a mentally and physically fit health workforce, alongside increased investment in their training to improve patient safety and healthcare quality, patients may ultimately suffer.</p>
<p><em>The authors wish to acknowledge Laura Wotton from the University of Global Health Equity who contributed to this article.</em></p><img src="https://counter.theconversation.com/content/147222/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The most sustainable and cost-effective solution for protecting patients’ lives is to reduce the causes of human error. Health professionals must be adequately trained to reduce adverse outcomes.Paul I Kadetz, Associate Professor/Chair of the Center for Executive Education, University of Global Health EquityAbebe Bekele, Deputy Vice Chancellor of Academic Affairs and Dean, University of Global Health EquityAgnes Binagwaho, Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1419002020-07-09T15:13:10Z2020-07-09T15:13:10ZBeyond Florence Nightingale: how African nurses have decolonised the profession<figure><img src="https://images.theconversation.com/files/346290/original/file-20200708-3991-aytiee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nurses attend the 2015 International Nurses' Day celebrations in Johannesburg, South Africa. </span> <span class="attribution"><span class="source">Ihsaan Haffejee/Anadolu Agency/Getty Images</span></span></figcaption></figure><p>This year – 2020 – marks the 200th anniversary of Florence Nightingale’s birth. It’s therefore understandable that it’s being marked as <a href="https://www.who.int/campaigns/year-of-the-nurse-and-the-midwife-2020">the year of the nurse and midwife</a>. </p>
<p>Nightingale is <a href="https://www.britannica.com/biography/Florence-Nightingale">best known</a> for her pioneering spirit and fearless approach to changing atrocious conditions and improving healthcare service delivery. These qualities still characterise the attitudes and habits of nurses around the world. They are often the only frontline healthcare workers caring for people – whether they are vulnerable and living in poor and isolated settings or well-off in rich parts of the world.</p>
<p>But Nightingale left two legacies. The other is less known. </p>
<p>She held strong prejudices against indigenous people. While she wasn’t afraid to challenge the status quo in some areas, her role in colonialism and her expressed attitudes towards indigenous populations was deeply concerning. So troubling in fact, that the New Zealand Nurses Organisation chose not to celebrate or acknowledge her birthday this year. The organisation <a href="https://croakey.org/nz-nurses-organisation-why-we-arent-celebrating-florences-birthday/">labelled</a> her </p>
<blockquote>
<p>statements on colonisation and the fate of indigenous people a dangerous legacy. </p>
</blockquote>
<p>They view Nightingale’s writing about indigenous peoples in the South Pacific as “racist, paternalistic and patronising”. </p>
<p>Both legacies had a profound effect on nursing, particularly in countries colonised by the British. Nursing and midwifery were formally established with the dawn of colonialism and Nightingale’s two legacies <a href="https://academicjournals.org/journal/IJNM/article-full-text-pdf/8C859081115">played a large role</a> in the structure and shape of nursing on the continent. </p>
<p>On the one hand nursing was recognised as the first modern clinical profession on the continent. On the other, patterns of racism as well as elitism were passed on too. These traits are reflected in a <a href="https://pubmed.ncbi.nlm.nih.gov/26186472/">paper</a> published five years ago on how institutional models and ideas were transported from colonial nursing leaders in Europe to African nursing students. The research was based on the oral histories collected from 13 retired nurses from Mauritius, Malawi and Togo who had studied and practised nursing from the late colonial era (1950s) through decolonisation and independence (1960s-70s).</p>
<h2>Legacies</h2>
<p>The British influence, through Nightingale’s post Crimean War reforms in nursing education, affected the nursing education and practice in African colonies in the early 20th century. In 1940, for example, Britain established a <a href="https://www.britishempire.co.uk/article/qeons.htm">Colonial Nursing Service</a>. The service sent British nurses to the Colonies to care, initially, for sick British personnel and subsequently for the indigenous populations. </p>
<p>The British style hospital-oriented system of training was adopted. This would continue for decades to the detriment of empowering nurses and decentralising nursing services to more remote and rural areas.</p>
<p>How nurses and midwives <a href="https://pdfs.semanticscholar.org/c338/99af7ad0fcd5e4f45b04426520abe4049f6f.pdf">were viewed was imported</a> almost without adaptation from Europe. For example, in France nurses are still perceived as a handmaiden to the doctor, with very little independent practice. Midwives are almost unknown. The severe shortage of midwives in many African countries speaks to the continuing dominance of non-applicable models in African health services.</p>
<p>The European style of nursing continued into post-colonial Africa. The oral histories of African nursing leaders describing their experiences in the post colonial period show vividly how colonial stereotypes dictated their lives.</p>
<h2>Evolution of nursing</h2>
<p>But their stories also attest to the fact that nursing slowly changed and evolved in different African countries. The nurses interviewed about nursing practices 50 years ago explained how they adapted European models and ideas to meet their own needs. </p>
<p>A particularly poignant example of this was the expressed desire of the nurses in the study to serve their country and help their country heal from the effects of colonialism.</p>
<p>Moreover, out of necessity, African nurses expanded their scope of practice in ways that only occurred decades later in countries with more resources. An example is in the prescribing of medication which was always the province of doctors, few of whom practice in rural and remote areas. Following the outbreak of the HIV pandemic, nurses in Africa began prescribing antiretroviral drugs. In countries like Uganda and Rwanda nurses began to prescribe oral morphine for pain management in cancer and related terminal diseases exacerbated by the high prevalence of HIV. </p>
<p>African nurses have also led the way in taking over tasks previously undertaken only by physicians. In Ethiopia nurses in rural and remote areas carry out caesarean sections. And in countries like South Africa, Kenya, Malawi, Uganda, and Zambia, there are clinical specialist roles in nursing and midwifery such as critical care nursing, palliative care nursing and perioperative nursing among many others. </p>
<p>Increasingly, the profession has moved to become autonomous, self-regulated, research-focused, and centred on the needs of the population. </p>
<p>This ability to move beyond traditional Western models of care has been important in the management of the disease profile of Africa, where geographical location has added to the burden of disease not found in developed countries. </p>
<h2>Paving a new way</h2>
<p>Given the events of 2020 it’s appropriate and fitting to applaud the visionary work of nurses because of their pivotal roles in addressing health inequity on the global stage. Nurses are commonly described as the <a href="https://www.who.int/publications/i/item/nursing-report-2020">“backbone”</a> of the health system. </p>
<p>Their inventiveness and ingenuity in adapting general practices to local conditions should be especially acknowledged. </p>
<p>For example, a <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001271.pub3/full?highlightAbstract=nurse%7Csubstitut*%7Cnurs%7Ccare%7Cprimary%7Cprimari">systematic review suggests</a> that nurse-delivered care in primary care settings generates similar or better outcomes than doctor-delivered care for a wide range of conditions. In addition, nursing-led primary care services can lead to similar – or even better – patient health outcomes and higher patient satisfaction than other care delivery models. This is because nurses have longer consultations with patients. </p>
<p>Other reviews have shown that nurses are effective in the initiation and follow-up of <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007331.pub3/full?highlightAbstract=initi%7Cmaintenanc%7Ctherapy%7Cshift%7Cfor%7Cmainten%7Cnon%7Cshifting%7Cdoctor%7Cantiretroviral%7Ctask%7Cinitiation%7Cdoctors%7Ctherapi%7Cantiretrovir%7Cfour%7Cof%7Cfrom%7Cto%7Cmaintenance">HIV therapy</a>. And that <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001188.pub3/abstract?cookiesEnabled">nursing interventions</a> for tobacco cessation increase the likelihood of quitting. </p>
<p>Further <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009149.pub2/abstract">research</a> has shown that non-specialist health workers, including nurses, may improve outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and patient and carer outcomes for dementia.</p>
<p>As the world continues to battle the COVID-19 scourge, their contribution has never been more profound. Nurses personify the indomitable trailblazing spirit Nightingale showed 200 years ago. But their song is now much richer and more humane. And their impact reaches much further in terms of addressing global health equity and championing the plight of the world’s most vulnerable populations.</p><img src="https://counter.theconversation.com/content/141900/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With the dawn of colonialism, nursing and midwifery were formally established and, in many colonies, recognised as the first modern clinical profession on the African continent.Timothy A. Carey, Director: Institute of Global Health Equity Research, Andrew Weiss Chair of Research in Global Health, University of Global Health EquityAgnes Binagwaho, Vice Chancellor, University of Global Health EquityJudy Khanyola, Chair, Center for Nursing and Midwifery, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1384602020-06-03T14:55:01Z2020-06-03T14:55:01ZCOVID-19 shows the world needs physicians who can look beyond medical charts<figure><img src="https://images.theconversation.com/files/339528/original/file-20200603-130951-1b0y43e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As modern medicine has advanced, so too has our understanding of what affects health. Over recent decades this has generated a number of new fields in medicine. One of the most important that has been born out of the latest generation is social medicine. It studies how social and economic factors help determine our health, specifically inequalities within societies that negatively influence health outcomes.</p>
<p>Similar <a href="https://pubmed.ncbi.nlm.nih.gov/19933684/">to primary health care</a>, social medicine prioritises health equity and promotes a broad view of health, multi-sectoral action and the participation of communities. Both significantly contribute to progress in improving <a href="https://pubmed.ncbi.nlm.nih.gov/19933684/">health equity</a>. </p>
<p>COVID-19 has placed a spotlight on the field of social medicine. It has done so by showing up inherent injustices in society. An example is the fact that African-American and Native American communities in the US are experiencing <a href="https://www.theguardian.com/world/2020/may/20/black-americans-death-rate-covid-19-coronavirus">disproportionate</a> COVID-19 deaths. The result is that more people are beginning to argue that social medicine should take centre state in the medical community. But the argument towards a more progressive approach to healthcare is also being <a href="https://www.wsj.com/articles/med-school-needs-an-overhaul-11586818394">met with criticism</a> by those who still cling to the traditional model of medicine.</p>
<p>The argument has come to head over approaches to medical education.</p>
<p>The main argument against a ‘social medicine’ orientation in medical education is that it comes at the expense of “practical preparation” in areas like pandemic response and disaster preparedness. In a recent article a professor of medicine, Stanley Goldfarb, went as far as <a href="https://www.wsj.com/articles/med-school-needs-an-overhaul-11586818394">to argue</a> that social medicine should be removed from “the traditional American model of medical training.”</p>
<p>We are firmly in the camp of those who believe that social medicine is an integral part of the formation of health care professionals. We strongly believe that our trainees and graduates need to be content experts and “practitioners”. But that they also need to understand the social determinants of health and diseases.</p>
<p>Both are necessary for an integral understanding of any major health challenges – including pandemics.</p>
<p>Our view is that it’s not a question of social medicine at the expense of emergency medicine. This is a false dichotomy. Increasingly research has shown that a <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1916269">multi-sectoral approach</a> is needed to deliver effective healthcare. Clinicians should understand how factors such as poverty, food insecurity and racism have an impact on the population health. This is particularly true for the most vulnerable.</p>
<p>Consider this example: it’s not an uncommon in many developing countries to see a malnourished child get admitted to a hospital with serious complications. They receive appropriate care – including food – recover significantly and are discharged in a very good state. But they are then readmitted with the same condition. </p>
<p>The “treatment” of this child is not only the hospital-based administration of the food and medicine. It goes far beyond to food security, safe water provision, environmental health and other determinants of health and disease.</p>
<h2>Both lenses are needed</h2>
<p>Doctors should be trained in emergency and critical care. They should also be trained in social medicine. Missing out on either renders responses inadequate.</p>
<p>One danger of a one-track approach to medical education is that it creates technically capable physicians who are dangerously unaware of the numerous factors that determine health on the individual, community and global level. </p>
<p>This makes them ill-prepared for the reality of clinical experience. </p>
<p>The reality is that an application of both social justice and a bio-social lens, which focuses on how social factors influence health, are needed to understand how different groups are uniquely affected by an event such as the current pandemic, how they access existing health services, and how this, in turn, can affect a nation’s pandemic preparedness and response. </p>
<p>For example, in the US the coronavirus is disproportionately affecting African Americans. In US hotspot Louisiana, more than 70% of COVID-related deaths have been among black Americans, despite making up only 33% of the population, according to the <a href="http://ldh.la.gov/Coronavirus/">Louisiana Department of Health</a>. </p>
<p>Health professionals need to understand why. One reason could be the <a href="https://www.nytimes.com/2020/01/13/upshot/race-and-medicine-the-harm-that-comes-from-mistrust.html">well-documented</a> mistrust of the US health sector, which has, in the past, compromised public health responses. This has been also documented in other parts of the world, such as during outbreaks of <a href="https://www.nytimes.com/2016/01/18/us/in-rural-alabama-a-longtime-mistrust-of-medicine-fuels-a-tuberculosis-outbreak.html">tuberculosis</a>, <a href="https://link.springer.com/article/10.1007/s10461-012-0323-x">preventing the spread of HIV in Africa</a>, and efforts to contain <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6762146/">Ebola outbreaks.</a></p>
<h2>Why social justice matters</h2>
<p>The experience of COVID-19 has been a case study in why medical students need exposure to more, not less, social justice issues. </p>
<p>There is a reason why medical schools globally are adopting these principles of social medicine, and why students <a href="https://www.wsj.com/articles/take-two-aspirin-and-call-me-by-my-pronouns-11568325291">encounter patients before they graduate</a>. </p>
<p>It comes back to the problem that has plagued the success of multiple health policies over time; how can you design and implement health systems, or treat patients, without understanding the historical, social, geographic and political circumstances of those you are serving? </p>
<p>An effective pandemic response can’t be separated from the how or the why of its arrival, the factors contributing to its transmission, or its devastating after effects. </p>
<p>Concentrating only on fundamental classroom training puts a metaphorical plaster on the wound, and simply awaits the next graze on the knee. Understanding how and why these diseases come to fruition, avoids taking these learnings into the future, and protects millions of lives.</p>
<h2>Putting patients at risk</h2>
<p>From our experience as health practitioners and health educators, medical education that is not patient centred and pinned around social medicine puts patients at risk. </p>
<p>Of course the world <a href="https://www.wsj.com/articles/med-school-needs-an-overhaul-11586818394">needs physicians</a> “who are better prepared to help battle deadly pandemic diseases like COVID-19”. But students also need enough bio-social tools and social justice training to prevent, respond, and disaggregate the burden of pandemics in a way that’s inclusive of everyone. And consequently benefit entire societies.</p>
<p>Not doing this increases the risk for all – even those who have the privilege of accessing care.</p>
<p>Only by training a new generation of physicians who can look beyond medical charts and see the bigger picture can we be prepared for the next pandemic – and any other health challenge we will face in the future.</p><img src="https://counter.theconversation.com/content/138460/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Removing social medicine from the education of medical students would be to their detriment - as well as their future patients.Abebe Bekele, Dean of the School of Medicine, University of Global Health EquityAgnes Binagwaho, Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1349082020-04-28T15:17:21Z2020-04-28T15:17:21ZCommunity health workers are crucial to pandemic response. How to support them<figure><img src="https://images.theconversation.com/files/330021/original/file-20200423-47788-8j8i9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A community health worker carries a box of protection masks in Dakar on April 16, 2020.</span> <span class="attribution"><span class="source">JOHN WESSELS/AFP via Getty Images</span></span></figcaption></figure><p>Almost all African countries <a href="http://covid-19-africa.sen.ovh/">have reported</a> cases of the new coronavirus disease (COVID-19). To contain the disease, they cannot rely just on doctors and nurses, who are already in short supply and at high risk of infection in the workplace. </p>
<p>The World Health Organisation (WHO) recommends that each country should have a minimum of 445 <a href="https://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf?sequence=1">healthcare workers</a> – such as doctors, nurses, and midwives – for every 100,000 people. But in sub-Saharan Africa, the ratio of healthcare workers to the population is very low: 46 out of 47 countries have <a href="https://ysjournal.com/the-critical-shortage-of-healthcare-workers-in-sub-saharan-africa-a-comprehensive-review/">significantly less</a> than this figure, though it does vary. For instance, in Rwanda <a href="https://data.worldbank.org/indicator/SH.MED.PHYS.ZS">there are</a> 10 doctors for every 100,000 people, while in Kenya <a href="https://data.worldbank.org/indicator/SH.MED.PHYS.ZS">there are</a> 20 and in Botswana <a href="https://data.worldbank.org/indicator/SH.MED.PHYS.ZS">there are</a> 40. </p>
<p>Since the <a href="http://ajph.aphapublications.org/doi/10.2105/AJPH.94.11.1884">1970s</a>, African countries have used community health workers to address gaps in the health workforce. These are local volunteers trained to provide basic health services. </p>
<p>They have effectively supported efforts to manage pandemics, including <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214180/">malaria, pneumonia and diarrhoea</a>, <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-12-71">HIV</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/30023054/">Ebola</a>. Their role is important because they can be trained to recognise symptoms, diagnose certain diseases, and even dispense medication. In addition, because they are long-time residents in their communities, they are known and trusted sources of information. </p>
<p>To help deal with the COVID-19 pandemic, some countries like <a href="https://amref.org/kenya/blog/community-health-workers-champion-kenyas-covid-19-response/">Kenya</a> and <a href="https://www.sciencemag.org/news/2020/04/south-africa-hopes-its-battle-hiv-and-tb-helped-prepare-it-covid-19">South Africa</a> have already mobilised community health workers. In Liberia they are helping to implement <a href="https://blogs.bmj.com/bmj/2020/03/27/prevent-detect-respond-how-community-health-workers-can-help-fight-covid-19/">prevention and control</a> measures.</p>
<p>But community health workers still face many challenges. For instance, they’re often not compensated enough for the work they do and aren’t given proper direction or training. </p>
<p>It’s important that these challenges are addressed so that they can be more effective – and better supported – when they carry out their work.</p>
<h2>Challenges</h2>
<p>The WHO has established a number of criteria for <a href="https://www.afro.who.int/publications/community-health-worker-programmes-who-african-region-policy-brief">effective community health programmes</a> in the COVID-19 response. The advice is to include them – at all levels – in emergency response forums, equip them with essential knowledge and skills, clarify their <a href="https://msmagazine.com/2020/04/06/the-job-description-for-a-covid-19-community-health-worker-and-how-this-could-fight-u-s-unemployment/">roles and responsibilities</a>, and provide them with essential tools to protect themselves from COVID-19 and prevent the spread of the virus. </p>
<p>But previous research shows that these boxes may not always be ticked. </p>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/30023054/">study into</a> the effectiveness of community health workers during the 2014-2016 West Africa Ebola outbreak found that the maintenance of primary care services and the Ebola response were hampered because community members were engaged late in the response. </p>
<p>A reason for this is that community health workers are poorly integrated into existing health systems. Countries didn’t build the management and training structure <a href="https://www.who.int/bulletin/volumes/91/4/12-109660/en/">required</a> for effective integration. A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599898/">study</a> in South Africa on the governance of community health worker programmes showed that this creates fragmentation in health care delivery and means the community health workers don’t contribute to important decisions. </p>
<h2>Compensation</h2>
<p>Another big concern is that community health workers don’t get enough support or aren’t well protected. Many, but not all, community health workers work as volunteers and therefore receive <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0312-3">no, or very little</a>, monetary compensation. </p>
<p>This <a href="https://pubmed.ncbi.nlm.nih.gov/30023054/">was highlighted</a> in the Ebola study. In the three Ebola-affected countries they received very small travel allowances. Without compensation workers couldn’t always make themselves available for their voluntary activities because of other commitments that brought them an income. It also meant that they couldn’t be held accountable for their responsibilities because they weren’t being paid. </p>
<p>This is a common challenge. A <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0312-3">recent study</a> on HIV service delivery in low-income countries found that, even though community health workers conduct emotionally and physically demanding tasks, their costs aren’t covered. For instance, they would have to pay their own transport fees to perform a job. This has an impact on the care they can provide and can also lead to them feeling disempowered. </p>
<p>The study also found that they often don’t have adequate training and supervision. Many community health workers have had their responsibilities <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0312-3">poorly explained</a> to them, causing some to assume roles that otherwise belong to higher paid and trained staff. This raises an issue of injustice and unfairness in management and treatment of community health workers and jeopardises the future of their profession.</p>
<p>A lack of support and supervision can also be found elsewhere. A study in Kenya saw that in some cases, community health workers <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442123/">are</a> spoken about or spoken for, but receive little support in practice. </p>
<h2>Moving forward</h2>
<p>Moving forward, governments must ensure that there is <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0312-3">better</a> coordination, political commitment and investment when it comes to community health workers. </p>
<p>Authorities should consider setting a minimum standard of compensation and community health workers and local authorities <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0312-3">should</a> openly talk about the burdens that workers may face and the need for solutions to overcome them. For instance, if community health workers have to travel long distances, resources such as bicycles should be set into programme budgets. </p>
<p>Community health workers should also be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442123/">given more say</a> in how programmes are designed. This will tap into their experience and make the aims more achievable in practice.</p><img src="https://counter.theconversation.com/content/134908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Anatole Manzi serves as deputy chief medical officer at Partners In Health and assistant professor at University of Global Health Equity. He is also an Aspen New Voices Fellow and founder of Move Up Global. </span></em></p>To contain COVID-19, African countries cannot rely just on doctors and nurses, who are already in short supply and at high risk of infection in the workplace.Anatole Manzi, Assistant Professor of Global Health, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1317882020-02-23T07:14:31Z2020-02-23T07:14:31ZRwanda is training health workers for an interconnected world<figure><img src="https://images.theconversation.com/files/315681/original/file-20200217-11017-12ny4wj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The links between people, animals and the environment call for a new approach to health.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Growing scientific evidence shows that environmental transformations such as climate change and pollution are linked to people’s health. The number of extreme events is <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60901-1/fulltext">increasing</a>, often driven by <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60901-1/fulltext">human activities</a>, and they often pose an immediate threat as well as having long-term health impacts. This is a future for which health professionals must be prepared. </p>
<p>The outbreak of the novel coronavirus disease, <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019">COVID-19</a>, is just the most recent example of the links between the environment, animals and the activities and health of people. The virus is suspected to have originated from a bat and been transmitted through an animal market in Wuhan, China. The 2002-2003 <a href="https://www.cdc.gov/sars/index.html">Severe Acute Respiratory Syndrome</a> pandemic was another global outbreak that was attributed to human interaction with wildlife.</p>
<p>The interdependency between humans, animals and the environment is becoming more pronounced. It’s time to approach health problems in a broad, interdisciplinary way. The attitudes and practices of the health workforce will have to change. </p>
<p>There is already a conceptual framework in place for this. It just needs to be adopted more widely and urgently, supported by policy and education. </p>
<p>The <a href="https://www.cdc.gov/onehealth/index.html">One Health</a> approach recognises the links between humans and their biophysical, social and economic environments. It sees these links reflected in the population’s state of health. One Health differs from other approaches to health as it considers the integrative effort of multiple disciplines working locally, nationally and globally to achieve optimal health for animals, the environment and humans.</p>
<p>Many international institutions, such as the World Health Organisation and the Centres for Disease Control and Prevention, have adopted One Health in principle. And it’s being integrated into academic programming, including medical and veterinary schools, to some extent.</p>
<p>The One Health approach emphasises the development of students who analyse, interpret and create plans for both the present and future worlds. It takes disciplinary strengths and their best practices and compels them to work together.<br>
It challenges existing barriers and provides a platform to consider innovative solutions. One Health embraces complexity and looks at the whole picture to identify changes that will have a health impact. It also looks for points where intervention creates change. </p>
<h2>One Health in Rwanda</h2>
<p>Rwanda is one country, among others in East Africa such as Kenya and Uganda, that is embedding One Health into its way of doing <a href="https://gh.bmj.com/content/2/1/e000121">things</a>. The country adopted the One Health approach in 2011. This was prompted by emerging and re-emerging infectious diseases and their potential impact on socio-economic growth. </p>
<p>One Health in Rwanda provides a formal, institutionalised, multi-sectoral and coordinated approach to detecting and responding to outbreaks and other health threats. Rwanda has the second highest population <a href="https://data.worldbank.org/indicator/EN.POP.DNST?contextual=max&locations=ZG-8S-Z4&most_recent_value_desc=true">density</a> in sub-Saharan Africa and borders countries where disease outbreaks such as <a href="https://news.un.org/en/story/2020/02/1057291">Ebola</a> and <a href="https://www.who.int/csr/don/25-october-2017-marburg-uganda/en/">Marburg</a> have occurred. This puts it at risk of health challenges at the human-animal-environment interface. It also has a strong network of community health workers, rapid response teams, and academic partnerships who champion the One Health approach.</p>
<p>Education of professionals is part of the plan. At the <a href="https://ughe.org/">University of Global Health Equity</a>, located in rural Rwanda, medical and Global Health graduate students are introduced to One Health through field-based learning. Site visits include a local pig farm, wetlands surrounding the campus, homesteads in the community and a model village where displaced people have been resettled. These visits allow students to see the links between animals, the environment and the health of humans. </p>
<p>For example, at the pig farm, students observe the direct interactions between the farmers, the pigs and the environmental setting the farm is located in. They learn about protective measures used to prevent zoonotic disease transmission from the pigs to humans and vice versa. They are able to ask the farm’s veterinarian questions about how they interact with health professionals around emerging diseases. </p>
<p>At the end of the programme, students will have acquired a diverse skill set and the management and communication training needed to respond to complex health challenges. For example, a medical doctor who participated in the site visits would ask patients more questions to determine patient history, such as whether they interact with animals. This more holistic approach to health may provide the clue to determine the cause of the patient’s condition.</p>
<p><a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-6772-7">Results</a> of these efforts in Kenya suggest that training the next generation of professionals to use the lens of One Health will help solve complex health challenges like global disease outbreaks.</p><img src="https://counter.theconversation.com/content/131788/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Phaedra Henley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The interdependency between humans, animals and the environment is becoming more pronounced. This calls for an interdisciplinary approach to health problems.Phaedra Henley, Director, Centre for One Health, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1299882020-01-15T14:07:49Z2020-01-15T14:07:49ZPasha 49: How Rwanda rebuilt a broken healthcare system<figure><img src="https://images.theconversation.com/files/310215/original/file-20200115-134809-1rxefmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Rwanda has made strides in its health sector in recent years. The country is noted for making faster than expected progress over the past 15 years in reducing deaths among children younger than five. This is the result of the work the government has done in building a strong health system and taking an inclusive approach to health coverage. But there are still challenges like maternal mortality, for example. </p>
<p>In today’s episode of Pasha, Agnes Binagwaho, Vice-Chancellor at the University of Global Health Equity in Rwanda, discusses how building trust among the public played a key role in the success of Rwanda’s health sector.</p>
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Read more:
<a href="https://theconversation.com/lessons-from-rwanda-on-how-trust-can-help-repair-a-broken-health-system-124183">Lessons from Rwanda on how trust can help repair a broken health system</a>
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<p><strong>Photo:</strong>
By beast01 – The flag of the country of Rwanda and stethoscope. The concept of medicine. Stethoscope on the flag in the background. <a href="https://www.shutterstock.com/image-photo/flag-country-rwanda-stethoscope-concept-medicine-1558572560">Shutterstock</a></p>
<p><strong>Music</strong>
“Happy African Village” by John Bartmann, found on <a href="http://freemusicarchive.org/music/John_Bartmann/Public_Domain_Soundtrack_Music_Album_One/happy-african-village">FreeMusicArchive.org</a> licensed under <a href="https://creativecommons.org/publicdomain/zero/1.0/">CC0 1</a>.</p><img src="https://counter.theconversation.com/content/129988/count.gif" alt="The Conversation" width="1" height="1" />
Rwanda has developed a strong, decentralised health system and addressed many of the major financial and geographic barriers people faced.Ozayr Patel, Digital EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1241832019-09-30T13:40:13Z2019-09-30T13:40:13ZLessons from Rwanda on how trust can help repair a broken health system<figure><img src="https://images.theconversation.com/files/294043/original/file-20190925-51405-nrqs3d.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C895%2C1000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Niyazz/Shutterstock</span></span></figcaption></figure><p>Seven countries around the world – three of them in Africa – have made faster than expected progress over the past 15 years in reducing <a href="https://data.unicef.org/topic/child-survival/under-five-mortality/">deaths among children younger than five</a>. These seven countries, Bangladesh, Cambodia, Ethiopia, Nepal, Peru, Rwanda and Senegal, were selected because they have all performed unexpectedly well in improving childhood health relative to their <a href="https://data.worldbank.org/indicator/NY.GDP.PCAP.KD.ZG">economic growth</a>. </p>
<p>There are many factors at the root of their achievements, most notably, a strong integrated and coordinated health system built on primary health care. However, one cross-cutting factor stands out that we believe allowed them all to achieve significant health gains but which, so far, tends to be always overlooked: trust.</p>
<p>This is clear from a <a href="https://wellcome.ac.uk/sites/default/files/wellcome-global-monitor-2018.pdf">report</a>, published by the Wellcome Trust and the Gallup Institute earlier this year. It surveyed 140,000 people in 140 countries to find out how they felt about science and health. </p>
<p>A study on public attitudes to science and health on a global scale, the survey covered topics such as whether people
trust science, scientists, and information about health; the levels of understanding and interest in science and health; the benefits of science;
the compatibility of religion and science; and attitudes to vaccines. </p>
<p>There’s a remarkable overlap between countries that have achieved progress in health goals such as reducing under-5 mortality, and those that ranked high in the trust survey. All seven were among the highest ranked globally when it came to their populations’ belief in the importance of vaccines while six out of the seven ranked highly in their trust in hospitals and health clinics. </p>
<p>There’s logic in this. With greater population trust in health systems, health uptake and health outcomes improve. People are more likely to understand the benefits of health services and place a high value in receiving these services. This includes trusting in vaccinations which would lead people to placing a high value on vaccinating their children.</p>
<p>Rwanda in particular has done well in building population trust. According to the survey, the country reports the highest levels of confidence in hospitals and health clinics in the world, and the largest proportion of the population who agree that vaccines are effective. Rwanda also comes out on top in the world in terms of how much of its population believes that vaccines are important for children and in <a href="https://data.unicef.org/resources/immunization-coverage-estimates-data-visualization/">the percentage of children who are vaccinated.</a></p>
<p>This is the result of the work the Rwandan government has done over the past 25 years to build a strong health system and foster an inclusive approach to health coverage, starting at a community level. These actions can serve as a model for other countries to replicate.</p>
<h2>Crucial steps</h2>
<p>It is 25 years since Rwanda was destroyed by the <a href="https://www.un.org/en/ga/search/view_doc.asp?symbol=S/1999/1257">1994 genocide</a> against the Tutsi. Since then, the country of more than <a href="http://www.statistics.gov.rw/statistical-publications/subject/population-size-and-population-characteristics">12 million</a> people has developed a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60574-2/fulltext?rss=yes">strong, decentralised health system</a> and addressed many of the major financial and geographic barriers that vulnerable populations face in accessing healthcare services. </p>
<p>Some of the steps have included:</p>
<p><strong>Prioritising programmes that leave no one out</strong></p>
<p><strong>Building a decentralised health system:</strong> There are 15,000 villages in Rwanda. By 2018, each one had <a href="http://www.rbc.gov.rw/index.php?id=19&tx_ttnews%5Btt_news%5D=447&cHash=c95bbbc0655d12b71c9ccdc675ab2313">four community health workers</a>. These community health workers are elected by their peers and are highly respected, trusted members of their communities who are spending sleepless night to keep their peers healthy. </p>
<p>The trust that’s been built between community health workers and the people they represent has provided a strong foundation in developing broader trust in health systems and in the government that created the system.</p>
<p><strong>Promoting the uptake of health services and vaccination service delivery</strong>: Community health workers, among other tasks, ensure that all pregnant women in their village attend antenatal clinics and deliver in a health facility, that every child gets vaccinated, and that community members are educated about the importance of vaccines and other preventive and curative treatments.</p>
<p><strong>Offering universal access to a range of treatments:</strong> For example, HIV prevention care and treatment services, including the use of antiretroviral treatment.</p>
<p>All these measures contributed to growing population trust in the health system. People feel more comfortable in seeking out healthcare at health facilities and trusting the advice given to them by health professionals. </p>
<h2>More work remains</h2>
<p>There have been <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60574-2/fulltext?rss=yes">tangible benefits</a> to this rebuilding. Life expectancy has doubled. Immunisation coverage rates also increased from less than 30% in 1995 (with five kinds of vaccines administered) to 94% in 2015, with <a href="http://www.nitag-resource.org/uploads/media/default/0001/03/ff28cb2c2cb72344d4d7416d8178b25407d57cbb.pdf">10 vaccines administered to boys and 11 administered to girls, including the HPV vaccine</a>.</p>
<p>This is not to say that Rwanda doesn’t have more work to do. That’s also true of that the other six countries that performed well in the Wellcome Global Monitor.</p>
<p>Education remains a critical gap. The Wellcome Global Monitor <a href="https://wellcome.ac.uk/sites/default/files/wellcome-global-monitor-2018.pdf">reported</a> that the seven countries had some of the highest population proportions with little to no knowledge of science, especially among older people.</p>
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<a href="https://theconversation.com/rwanda-university-sets-out-to-teach-doctors-medicine-and-management-110527">Rwanda university sets out to teach doctors medicine and management</a>
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<p>A lack of science education is a major barrier to improving health outcomes and achieving and sustaining <a href="https://www.who.int/health_financing/universal_coverage_definition/en/">universal health coverage</a>. Strong education systems that are training our scientists, clinicians and health professionals are crucial to ensuring countries have enough skilled professionals to provide high quality care to everyone. </p>
<p>This is a gap we are trying to fill at the <a href="https://ughe.org/">University of Global Health Equity</a> in the rural north of Rwanda: to train future clinicians to have the tools to effectively address inequities in healthcare and to build and maintain health systems that leave no one out.</p><img src="https://counter.theconversation.com/content/124183/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Professor Agnes Binagwaho is the vice-chancellor of the University of Global Health Equity</span></em></p><p class="fine-print"><em><span>Miriam Frisch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rwanda’s government has taken concerted, deliberate steps over the past 25 years to build a strong health system.Agnes Binagwaho, Vice Chancellor, University of Global Health EquityMiriam Frisch, Research Associate to the Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1105272019-02-05T13:43:27Z2019-02-05T13:43:27ZRwanda university sets out to teach doctors medicine and management<figure><img src="https://images.theconversation.com/files/257260/original/file-20190205-86195-1uq6dwv.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Master of Science in Global Health Delivery Class of 2018</span> <span class="attribution"><span class="source">Photo by Jean Christophe Kitoko for UGHE</span></span></figcaption></figure><p><em>A new university of health sciences is being launched in Rwanda. The <a href="https://ughe.org/">University of Global Health Equity</a> is being touted as a centre that will “contribute to addressing the critical shortage of health professionals” and “ensure they remain committed to the continent”. The Conversation Africa’s Moina Spooner spoke to the University’s Vice Chancellor, Agnes Binagwaho, about why Africa has a shortage of health professionals and what can be done to overcome it.</em></p>
<p><strong>Why does Africa have a shortage in health professionals?</strong></p>
<p>Africa <a href="https://www.clomedia.com/2017/11/17/state-health-care-worker-shortage/">isn’t the</a> only part of the world with a shortage of health professionals, but <a href="https://ourworldindata.org/burden-of-disease">it has</a> a very high disease burden, with a very low percentage of the global workforce. This means that the shortage is more acute.</p>
<p>We have a lack of doctors and nurses, but also a lack of specialists like paediatricians, psychologists, surgeons, oncologists, and physiotherapists. Additionally, there are forms of care that are not well developed on the continent yet, like geriatrics and neonatal care. </p>
<p>There are many reasons for this. One major reason is that there aren’t enough institutions or teachers to train them. Per capita, Africa <a href="https://www.who.int/bulletin/volumes/86/7/07-046474/en/">produces fewer</a> doctors than any other part of the world. </p>
<p>The current level of socioeconomic development is one of the reasons for the lack of institutions. For instance, in Rwanda, during the colonial time period, no universities were producing doctors and we can now see the results of that delay. In 1963, the first university was set up, but it took about seven years before it graduated its first class. </p>
<p>Getting an education abroad was very expensive for families. And if students did go abroad, the type of medical education they received might not have suited the African context – for instance, they may be educated in diseases that are not the most important for our environment and acquire skills that are not suited to the needs of their home context.</p>
<p>Another important problem that contributes to the shortage of doctors is brain drain. Many health professionals <a href="http://www.bioline.org.br/pdf?jh06022">leave</a> Africa to work in other parts of the world, and developed countries take them at no cost. This further slows Africa’s socioeconomic growth. As it is, we don’t produce enough compared to other continents, and many health professionals then leave the continent to got to countries like the US or Middle East. This <a href="http://www.bioline.org.br/pdf?jh06022">results in</a> a loss of health services, human development investment, supervisors, and mentors.</p>
<p>The shortage, of course, is felt more in some areas than others. It’s also felt more acutely after unrest or epidemics.</p>
<p><strong>What additional skills do medical professionals need in African countries?</strong></p>
<p>In the developed world, the doctor goes into his or her clinic in the morning, works through his or her patient list or appointments, and then leaves at the end of the day. There are people to manage the hospital, order the drugs and equipment, organise the maintenance of equipment and the improvement of the infrastructure. </p>
<p>But in many African settings, doctors need to know how to manage all of this. They need to have managerial skills that can contribute to building the system in which they will perform. In addition to these skills, they also should know how to equip systems for epidemic outbreaks, how to prevent diseases they might face, and how to be better equipped to cure these diseases because drugs and equipment take longer to reach their hospitals than hospitals in the developed world. These extra skills are essential for our doctors and nurses, and this is what we teach at the <a href="https://ughe.org/">University of Global Health Equity</a>. </p>
<p>Clinicians also must build systems with task-shifting ingrained in them. For example, if you have someone with malaria, there’s no need to go to a health facility. You can have trained community health workers, monitored by a health professionals, to diagnose and treat malaria. Most cases aren’t complicated. And, if the case is complicated, they can be transferred to health facilities. This is a system that won’t overuse the skills of doctors and nurses. </p>
<p><strong>How will the university address these challenges?</strong></p>
<p>The University of Global Health Equity will educate health professionals with the extra skills that they need, including managerial and leadership skills. They will also have a better understanding of the social determinants of health – for instance understanding that where people live may be causing an illness and addressing it – and all the principles of building a health system that ensures everyone can access services.</p>
<p>All our clinicians graduates will have a dual degree when they leave the university. They will be medical doctors and they will have a Masters in Global Health Delivery. That means they have a masters in building systems, doing quality research, training, and doing advocacy for the provision of better care.</p>
<p>This will help address issues of brain drain. Many health professionals leave the continent because they don’t know how to handle the non-clinical systemic problems in the health sector and don’t have the skills to be part of their solution. This means they may be discouraged and go somewhere where it’s easier to work. But with the capacity to build the system to exercise their skills, health professionals will be more inclined to stay. </p>
<p>Our institution will also support students after they graduate. We have a system that allows us to follow our alumni closely. They come back to us if they have questions, if they have a problem that is new for them, or if we can help them create connections. That also helps them sustain their stay wherever they are. </p>
<p><em>Agnes Binagwaho is a Rwandan paediatrician that practiced for over 15 years before serving as the Minister of Health of Rwanda from May 2011 until July 2016.</em></p><img src="https://counter.theconversation.com/content/110527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Binagwaho is the vice-chancellor of the University of Global Health Equity</span></em></p>Many health professionals leave Africa because they don’t know how to handle the non-clinical systemic problems.Agnes Binagwaho, Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/820142017-08-10T17:26:11Z2017-08-10T17:26:11ZThe secret behind Rwanda’s successful vaccination rollouts<figure><img src="https://images.theconversation.com/files/181289/original/file-20170807-27840-17vqe3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rwandan girls were targeted in the country's successful HPV vaccination programme.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The best medical treatment option in the world can’t save a single patient unless it is delivered at the proper time, with the proper plans and processes in place. </p>
<p>That’s why <a href="http://bit.ly/1Nr3S1Q">implementation science for health</a> matters. It can best be described as a collection of principles that, if applied, will ensure the best possible health care is delivered to a specific community. It involves using <a href="https://www.ncbi.nlm.nih.gov/books/NBK2659/">evidence-based research</a>
to identify the obstacles to delivering health services, and the best ways to overcome them. The research must take into account things like geographical limitations, the social and economic make up of a community as well as cultural practices. Once established for one community, the methodology can be reused in others. </p>
<p>Through my own experience – as an academic and as former health minister of Rwanda – I am convinced that, unless we adopt this approach we won’t be able to achieve universal health coverage and other <a href="http://bit.ly/1FVTbUr">United Nation’s Sustainable Development Goals</a>. This is particularly true for Africa where health services are stretched because of a lack of resources. </p>
<p>If we incorporate efficient, evidence-based practices into our service delivery models in Africa we’ll save millions of lives, as well as millions of dollars. </p>
<p>A vaccination programme rolled out in Rwanda illustrates what I mean.</p>
<h2>The Rwandan example</h2>
<p>In 2011 Rwanda began a <a href="http://bit.ly/2vCeUoo">vaccination programme </a> for <a href="http://bit.ly/2gCyxk8">human papillomavirus (HPV)</a> – the most common sexually transmitted disease in the world. 33 countries <a href="http://bit.ly/2utSlgP">had rolled out</a> vaccination programmes, but few of them were in developing countries and none were in Africa. </p>
<p>In 2010, when we were preparing our first campaign, Rwanda seemed an improbable candidate for achieving near-universal HPV vaccination coverage. After all, we were ranked the 15th poorest nation in the world. International <a href="http://bit.ly/2vBYFaQ">skeptics </a>argued that developing countries couldn’t manage because of their weak scientific base, poor infrastructure, economic difficulties and overemphasis on curative, rather than preventative, medicine. </p>
<p>At the time even the developed world had achieved only moderate coverage of HPV vaccinations. The US had less than <a href="http://bit.ly/2v8MEXt">35%</a> of its adolescent female population fully vaccinated, and France also had a <a href="http://bit.ly/2fhRFsS">low coverage</a>. If countries like this couldn’t realise HPV universal vaccination roll-outs, how could low and medium income countries manage? </p>
<p>But we weren’t deterred. We convinced HPV vaccine producers to ignore the global disapproval by presenting our evidence-based strategy of how we would roll-out a programme across the country. They listened, and then signed a public private partnership agreement, which <a href="http://reut.rs/2udXr5j">funded the programme</a>.</p>
<p>Despite the seemingly impossible odds, Rwanda achieved <a href="http://bit.ly/2vrP4TJ">93%</a> HPV vaccination coverage within a year of initiating the campaign. The coverage level has been <a href="http://bit.ly/2whc717">maintained ever since</a> </p>
<p>What is the secret to Rwanda’s success? The answer is simple. We put our trust in implementation science. </p>
<h2>Implementation science in action</h2>
<p>For the rollout we collected evidence, adapted distribution methods to our setting and set clear targets and outcomes.</p>
<p>Every step of HPV distribution was evidence-based. To analyse the cultural implications of our program, the Ministry of Health conducted a series of interviews and discussions with community members. We set up a task force which included all stakeholders - religious, educational, political, parliamentary, and community leaders - and designed a strategy of nationwide community education to spread awareness of cervical cancer, the benefits of the vaccine, and the proper time to receive it. Since almost all types of cervical cancer are caused by the human papillomavirus, it was important first <a href="http://bit.ly/2gU2Qqs">to explain</a> the link with cancer. </p>
<p>Using the same focus groups, we developed a method of defining and reaching the target population. Since HPV is a sexually transmitted disease, we wanted to vaccinate girls before they became sexually active. The task force researched the proper age bracket for this. Its conclusion was that a school-based vaccination scheme of 12-year-old girls would be most effective. Over <a href="http://bit.ly/2vA3alH">97%</a> of female Rwandan pre-teens are enrolled in primary school and few have sexual intercourse at that age. </p>
<p>Another research component was on the cold chain management. We needed to know how much vaccine to procure, how much storage space and money this would require, how many transport vehicles we would have to mobilise and where to send them. We also drew from our experience in rolling out other vaccination programs to create a rotating decentralized storage system. </p>
<p>Once all the evidence had been evaluated, we put a detailed delivery plan in place. We organised a distribution system to transport the vaccine from the cargo plane, to Kanombe International Airport, to the national warehouse, to the 30 district hospitals, to the 436 health centres – at that time, to the primary schools.</p>
<p>We also collaborated with Rwanda’s 45000 community health workers and all the teachers concerned. They identified girls who were absent from school on the day of vaccination to make sure they were covered too. And teachers were taught how to monitor students in the days after the vaccination so that they could report any adverse side-effects and be a key pillar of the HPV vaccine pharmacovigilance system.</p>
<p>The principles of implementation sciences applied for the success of the HPV vaccination roll-out have been used in other vaccination campaigns. Today in Rwanda we have more than 90% of all children fully vaccinated for 11 vaccines, with an additional <a href="http://bit.ly/2vA2jkG">HPV vaccine for all girls</a>.</p>
<h2>The need for research and education</h2>
<p>As Vice Chancellor of the University of Global Health Equity in Rwanda we are introducing researchers to implementation science.</p>
<p>Like any science, it requires research. At the moment, the global focus (and therefore global funding) is on clinical research and fundamental sciences. Last year less than 2% of all <a href="http://bit.ly/2vBWhAW">research grants</a> offered by the National Institute of Health, the largest funder of health research in the world, have been dedicated to implementation science. </p>
<p>But to improve health care we must also invest in implementation research to improve service delivery. Sure, we need basic science to create cheaper, more effective technology. But we also need implementation science to provide cost-effective ways of delivering and promoting universal health coverage.</p><img src="https://counter.theconversation.com/content/82014/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Binagwaho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rwanda’s vaccination programme for girls against HPV, the most common sexually transmitted disease was a huge success, thanks to implementation science.Agnes Binagwaho, Vice Chancellor, University of Global Health EquityLicensed as Creative Commons – attribution, no derivatives.