blue skies and rainbow

A round table for Immunization Agenda 2030: The leap from “bottom-up” consultation to multidimensional dialogue

Reda SadkiGlobal health

They connected from health facilities, districts, and national teams all over the world. 4,769 immunization professionals from the largest network of immunization managers in the world joined this week’s Special Event for Immunization Agenda 2030 (IA2030), the new strategy for immunization, with 59 global and regional partners who accepted the invitation to listen, learn, and share their feedback. (The Special Event is now being re-run every four hours, and you can join the next session here.)

“My ‘Eureka moment’ was when the presenter emphasized that many outbreaks are happening throughout the globe and it is the people in the room who can steer things in a better direction”, shared a participant. “This gave me motivation and confidence that by unifying on a platform and by discussing the challenges, we can reach a solution.”

Two of the top global people accountable for executing this new strategy, WHO’s Ann Lindstrand and UNICEF’s Robin Nandy, were in attendance. “With such commitment”, said Robin Nandy, “I am confident that we can achieve the goals of IA2030. Let us be mindful of the importance of convenient and high quality services delivered by a well informed workforce, which you all embody.”

Hearing “invaluable insights”, Ann Lindstrand recalled that “IA2030 was developed with thousands of immunization stakeholders like you. It reflects exactly what you are telling today. I am encouraged to hear your analyses and ideas to face our common challenges.”

Indeed, in developing Immunization Agenda 2030 intended to be “adaptive and flexible”, global partners employed a “bottom-up co-creation process”, described as “close engagement of countries to ensure that the vision, strategic priorities and goals are aligned with country needs.”

There is, however, a risk of confirmation bias. Staff from countries do their best to carry out what they have been asked to do. In the conventional top-down hierarchical system, global recommendations are adopted by ministries of health that then command staff to execute them. If the system remains overly rigid, staff who want to keep their jobs are likely to confirm and comfort the assumptions of the higher-ups whose vision they have been tasked to implement, no matter the depth of the chasm between these assumptions and reality.

During the Teach to Reach Accelerator conference in January 2021, Kate O’Brien, the director of WHO’s Immunization Department, pointed out that the term “bottom-up initiative” does not call into question existing hierarchies: “I don’t like the sort of hierarchy, about this is the bottom and this is the top, it has a certain sort of power element to me. […] I think leadership is about sitting around a table with a group of people, and drawing the best ideas from everybody who’s sitting around that table, wherever they come from.”

Of course, immunization programmes have a strong technical dimension that require standardization. There are critical elements required for safe and effective vaccination. For example, WHO now organizes weekly didactic Q&A webinars (with Project ECHO, a fascinating organization of doctors exploring new ways to learn, and TechNet-21, a pioneering digital platform for immunization) that do the job of transmitting information to people involved in COVID-19 vaccine introduction. However, we know that information is necessary but insufficient to lead to the effective localization and application of standards. 

As Kate O’Brien explained, “we need people to feel like they have the authority and are empowered to lead change in their community, in their programme, at the most local level, understanding what the goal is and what the targets are, taking those critical things that really cannot be compromised and adapting all around that.”

The IA2030 framework is, according to its global custodians, “designed to be tailored by countries to their local context, and to be revised throughout the decade as new needs and challenges emerge.” In line with this vision, global partners are hoping to foster a “groundswell of support” or even a “social movement”, to ensure that immunization remains high on global and regional health agendas in support of countries.

Alicia Juarrero, whose research focuses upon complex systems’ models of neural processes involved in proto-moral, moral and ethical cognition, emotions and behaviors, has made the compelling point that requires us to restructure what she calls the “space of possibility”. Continuous dialogue enabled by digital technologies can cut across hierarchies and borders to help create such a space. This represents a logical and constructive shift from “bottom-up” toward what Ian Steed has called multidimensional dialogue.

Such a dialogue is likely to be different from what global partner staff are used to. It may be interesting, yet feel somehow illegitimate, if only because challenging the status quo may not be in their job description. Some may question its relevance. “This is just not how we do things in immunization,” is how one partner rebuked us in private. Others may even feel threatened, choosing to ignore or dismiss it, even if their organization’s mission is to support countries and people who deliver vaccines. Certainly, what is emergent is far from perfect and requires continued improvement to be truly inclusive of all voices and stakeholders needed to achieve the immunization goals. Nevertheless, participants in this week’s global round table collectively expressed the feeling of empowerment that stems from being connected in a global community for action. Combined with active presence and strong support of organizational leaders, it is moments like these that can spark new consciousness and could foster the birth of a movement.

Image: Rainbow above the clouds. Personal collection.