Interplay between climate and health

What does immunization have to do with climate change?

Reda SadkiGlobal health, Thinking aloud

With climate-driven shifts in disease patterns and emerging health threats, the need for a robust immunization infrastructure is more obvious than ever. As the demand for both existing and novel vaccines rises in response to an expanding disease burden and new health threats, immunization staff will inevitably play a key role.

Immunization staff, trusted health advisors to communities, already stand as sometimes-overburdened but always critical actors in resilient health systems.

These professionals, entrusted with administering vaccines, contribute to preventing disease outbreaks and maintaining population health. Furthermore, their direct engagement with local communities, their intimate understanding of community health concerns, and their role as trusted advisors position them to recognize and respond to emerging health needs.

The role of immunization and other primary health care (PHC) staff as health educators becomes increasingly pertinent in a changing climate. By leveraging their experience in working with communities to understand and accept health interventions, immunization staff can help those they serve to make sense of the complex relationships between climate and health – and develop appropriate responses.

Through digital networks, we see health professionals connected to each other, learning from each other’s successes, lessons learned, and challenges. We imagine that these networks, if properly nurtured and sustained, will become increasingly important as health workers face the interconnected consequences of climate change on health within the local communities where they work for health. This also require new ways of thinking and new leadership, in addition to a new kind of digital health infrastructure to support turning learning into action.

As we step into a world facing escalating health threats from a changing climate, the crucial role of immunization staff in protecting communities will become more pronounced.

Existing approaches – even the ones that so impressively moved the needle of vaccination coverage and health in the past – may now need to be reconsidered and adapted to face new challenges and new threats that we know are coming.

By supporting the will and commitment of immunization staff who are concerned about the consequences of climate on health, and then expanding to include other health professionals, we may find that immunization can serve as a pathfinder to strengthen health systems and promote health equity. We may even find practical, meaningful ways for frontline health professionals and communities to forge together a new leadership for global health.

Learn more about the Geneva Learning Foundation’s special event: From community to planet: Health professionals on the frontlines of climate change.

Analog gates or digital bridges.png

Digital bridges cannot cross analog gates

Reda SadkiGlobal health, Thinking aloud

I’ve been doing a lot of thinking recently about an interesting question, as I’ve observed myself and colleagues starting to travel again: “Why are we again funding high-cost, low-volume face-to-face conferences that yield, at best, uncertain outcomes?”

I am surprised to have to ask this question. I was hoping for a different outcome, in which the experience of the COVID-19 pandemic led to a lasting change in how we bridge physical and digital spaces for a better future. We were brutally forced to work differently due to the COVID-19 pandemic’s restrictions on freedom of movement. Nevertheless, we discovered that it is possible to connect, meet, collaborate, and learn without sinking budgets into air travel and accommodation. At least some of work-related travel was due to habit and convention, not necessity. Yes, there were limitations, especially due to the emergency nature of the pivot to online. But the debate is open whether the limitations we experienced being forced to work online are more or less severe than those of the offline medium.

In global health, traditional face-to-face meetings, workshops, and conferences have been part and parcel of professional life for decades. They served their intended purpose, helping staff connect formally and informally, providing the connective tissue to learn, share, and coordinate. They have been – and remain – deeply ingrained in the culture of global health. Why should this modus operandi be reconsidered?

As someone who is often required to attend face-to-face conferences, despite being a vocal advocate for more efficient, inclusive models, here is how I understand both sides of the dichotomy that this scenario presents.

Traditional face-to-face meetings, workshops, and conferences offer a unique charm. They allow the select few to reconnect with colleagues, stay updated on institutional developments, and keep fingers on the pulse of the latest changes in our fields. Information can be shared informally, which is far more difficult to do online. (This is not inherent to the online medium, but due to the technologies we have developed that assume, support, and structure formal communication.) If you were invited or selected to be at the meeting, that indicates to those in the room that you are a valid stakeholder.

There is a considerable downside. These events are exclusionary by definition. Not everyone’s costs can be covered. Selection is often based on hierarchy. Often, only the most senior get to go. When less senior practitioners are included, tokenism is difficult to avoid. Then, there is the high cost. It is primarily expenditure on travel and hotels, not event quality. There is also the cost to the environment. Think of the carbon footprint. They are disruptive to everyday work, as attendance requires absence. Strangely, their impact is seldom measured, evaluated, or questioned.

The same donor who will unquestionably plunk down $150,000 for the plane tickets and hotels rooms of 100 people might require the evidence of a randomized controlled trial (RCT) before investing in a new digital learning approach that might include 1,000 or 10,000 people for the same cost and produce far more significant outcomes than a meeting report.

So why are face-to-face events still being funded, at high cost and questionable return, when global health is supposed to be evidence-based and focused on impact?

Ironically, as Girija Sankar made the case recently in The Lancet, the very conferences designed to push the boundaries of research and collaboration in global health often act as “gates,” creating a divide between insiders and those on the outside. These gatherings are often arranged by the gatekeepers of global health, the credentialed leaders who control funding and policy. Their decisions shape the future of health at a global level, conferring agency upon a select few while inadvertently excluding many others.

It is undeniably satisfying – and deeply so – to connect with colleagues over the course of several days, sharing conversation, meals, coffees. It is not only about listening and learning. It is about being human together, despite the constraints and urgencies of the work. So, if you are in a position to fund such an event for yourself or for your colleagues, why would you say no, given the obvious benefits and zero incentive to deny your colleagues what they are used to getting?

The value of such events is in part premised on their exclusivity. Letting everyone in could dilute their value. Furthermore, digital experience remains awful: a Zoom call is undeniably inferior to the experiential richness and pleasure of a meeting in a shared physical space.

Unfortunately, as long as such wonderful moments are reserved for the few – due to the nature of the medium, despite the best intents –, such communion stops at the conference walls – and excludes everyone outside them.

The Geneva Learning Foundation’s Teach to Reach program presents a stark contrast to this traditional model. Our online, digital, and networked peer learning events are dynamic, inclusive, connecting local practitioners from everywhere. With no upper limit on participants, these digital events rally thousands from all corners of the globe, providing an unparalleled platform for shared learning and action.

The upcoming Teach to Reach 8 event on 16 June 2023 is a testament to this, with over 16,000 anglophones and francophones already registered to join. Most notably, the majority of participants are government health workers working on the frontlines in Africa and Asia. Teach to Reach is led by an “organizing committee” composed of 282 Teach to Reach Alumni from 35 countries who are founding Members of the Global Council of Learning Leaders for Immunization in November 2020.

Some global-level colleagues who have rejoined the mission travel, conference, and workshop circuit share that they struggle to understand Teach to Reach. It is just too different from what they are used to. They have to painstakingly listen to staff with lousy connectivity who share local experiences, problems, and challenges that seem quaint, compared to the abstract global-level strategies they usually engage peers who are almost exactly like themselves. Such sameness is reassuring. Comparatively, Teach to Reach is too chaotic and noisy. So many voices, speaking from so many different pespectives. Too time-consuming. Too confusing. Too different from what “we” are used to. Too messy. 

Yet, the real world is messy. We know that the probability of finding a solution locally increases with the number and diversity of inputs available. At Teach to Reach, thousands share their experience, using a robust, proven peer learning model. The global experts who do attend do so as “guides on the side” rather than “sages on the stage”.

The unstated, underlying assumption of many so-called capacity-building initiatives is that the locals do not know. Therefore, “we” must teach them. There is no way to call this anything other than a colonial assumption. Recognizing the value and significance of local expertise and experience may have been less important in the past, when countries successfully carried out effective top-down strategies that moved the needle of vaccination coverage across the world. Today’s more complex immunization challenges require problem-solving approaches that recognize that context is central. What you know, because you are there every day, side-by-side with families and communities that you serve, turns out to be more important than generalities.

For example, the Foundation’s research has shown that reaching zero-dose or underimmunized children calls for local creativity to tailor and adapt strategies, rather than apply a cookie-cutter guideline. Should we be searching for generalizations that can be turned into norms and standards, when every zero-dose context is different? What if the opportunity were to hone in on the ‘how’ of local action, to better understand what makes the difference at the last mile of service delivery?

Should we assume that it is local staff who need to develop their capacity and change, when behavior change is probably necessary for everyone, at all levels?

Change is hard, but it is definitely happening. The last two editions of Teach to Reach have been in partnership with UNICEF and since 2022 with support from Wellcome. Ephrem T. Lemango and Kate O’Brien, who lead immunization at UNICEF and WHO respectively, prefaced the latest Teach to Reach report, writing: “Uniquely, the Geneva Learning Foundation’s platform and its Teach to Reach events provide a way to link such people together, so that they can share experiences about what works and equally important, what doesn’t work, while learning from each other. Learning happens best when people seek answers to their specific daily challenges. Teach to Reach is proof that immunization professionals are hungry to learn, and hungry to share.”

Furthermore, they note that “it is humbling to hear how committed people are to sharing experiences in the hope that they will benefit someone else, how the inadequacies of internet connections fail to deter people participating, and how so many are using precious digital data to take part. The digital space allows everyone to participate, irrespective of national boundaries or positions in an immunization hierarchy.”

Girija Sankar also reminds us that gatekeeping is not only for the leaders. It is also an opportunity for each of us to consider our roles and responsibilities. When deciding on invites, we should ask ourselves, “Is the limitation due to budget constraints or based on our perception of who has the most valuable input or the most funding to contribute?” It is also a call to action for those of us who have access to closed-door meetings or sit on advisory boards. We must pause and reflect on our roles and use our authority to pave the way for those who might not traditionally have a voice in these important discussions.

So, while I, and many others, have to travel to face-to-face conferences to stay “in the loop”, it is essential to recognize the limitations of these gatherings and work towards more inclusive and efficient models. The need to shift our mindset is more pressing than ever in the field of global health. In our quest for a healthier world, let’s ensure that the gates of knowledge and decision-making are open to all. Let’s embrace models like Teach to Reach, breaking down barriers and creating an inclusive platform for dialogue, learning, and action.

Imagine if the World Health Organization’s unspent mission travel budget in 2020 – around $400 million – had been invested in digital infrastructure to support continuous learning to explore and support new kinds of collaboration between different levels of the health system.

Le Lac Tchad

Why an open-source manifesto for global health?

Reda SadkiGlobal health, Global health, The Geneva Learning Foundation

Lire la version française: Pourquoi un manifeste open-source pour la santé globale?

The global immunization community is now focused on “the big catch-up”, dealing with recovery of immunization services from the consequences of the COVID-19 pandemic, as countries – and immunization staff on the frontlines – work toward the goals of Immunization Agenda 2030 (IA2030).

At the Seventy-Fourth World Health Assembly, the Director General of the World Health Organization had called for “a broad social movement for immunization that will ensure that immunization remains high on global and regional health agendas and help to generate a groundswell of support or social movement for immunization”.

A Movement is larger than any one individual or organization. The Geneva Learning Foundation is one of many working to support this Movement. In March 2022, we launched a call for immunization staff at all levels of the health system to connect across boundaries of geography and hierarchy – to commit to working together to achieve the goals of Immunization Agenda 2030 (IA2030).

In 2022, over 10,000 health professionals, primarily government workers from districts and facilities, joined this movement and shared ideas and practices, analyzed root causes of their local immunization challenges, and developed and implemented corrective actions to tackle them, together. Learn more…

Today, we share an open-source Manifesto for how health services could develop in ways that we think would make them more effective, recognizing health workers and communities – and the expertise and experience they hold because they are “there every day” – at the centre of public health systems.

No vision or strategy can or should be developed as a pronouncement by a single organization of how things should be.

  • This Manifesto is an open-source draft because, in today’s complex world, we tackle challenges that no one country or organization can possibly overcome alone.
  • For such a manifesto to be meaningful requires the participation, and contribution of those on the frontlines of global health, in dialogue with global, regional, and country leaders.

This is why we are inviting you – along with more than 10,000 members of the Movement for Immunization Agenda 2030 (IA2030 – to bring to life and shape this Manifesto.

Version 1.0 of the manifesto was first shared in a special issue of The Double Loop, the Geneva Learning Foundation’s insights newsletter. Learn more…

Le Lac Tchad

Pourquoi un manifeste open-source pour la santé globale?

Reda SadkiGlobal health, The Geneva Learning Foundation

Read this in English: Why an open-source manifesto for global health?

La communauté mondiale de la vaccination se concentre désormais sur le « grand rattrapage », en priorisant le rétablissement des services de vaccination suite aux conséquences de la pandémie de COVID-19, alors que les pays—et le personnel de la vaccination en première ligne—s’efforcent d’atteindre les objectifs du Programme pour la vaccination à l’horizon 2030 (IA2030).

Lors de la soixante-quatorzième Assemblée mondiale de la santé, le directeur général de l’Organisation mondiale de la santé avait lancé un appel en faveur d’un « vaste mouvement social pour la vaccination qui veillera à ce que la vaccination reste une priorité dans les programmes de santé internationaux et régionaux et contribuera à susciter une vague de soutien ou un mouvement social en faveur de la vaccination ».

Un mouvement est plus grand qu’un seul pays ou une seule organisation. La Fondation Apprendre Genève est l’une des nombreuses organisations à œuvrer pour insuffler ce Mouvement. En mars 2022, nous avons lancé un appel au personnel chargé de la vaccination à tous les niveaux du système de santé pour tisser des liens par-delà des frontières géographiques et s’engager à travailler ensemble pour atteindre les objectifs de «IA2030». En 2022, plus de 10 000 professionnels de la santé, principalement des fonctionnaires et des acteurs de la société civile issus des districts et des établissements de santé, ont rejoint ce mouvement. Ensemble, ils ont partagé des idées et des pratiques, analysé les causes profondes de leurs difficultés locales en matière de vaccination, et élaboré et mis en œuvre des mesures correctives pour surmonter leurs défis.

Aujourd’hui, nous partageons ce manifeste «open source» sur la façon dont les services de santé pourraient se développer de manière à les rendre plus efficaces, nous reconnaissons les professionnels de la santé et les communautés—ainsi que l’expertise et l’expérience qu’ils détiennent parce qu’ils sont « là tous les jours »—au centre des systèmes de santé publique.

Ce Manifeste est un projet «open source» car, dans le monde complexe d’aujourd’hui, nous sommes confrontés à des défis qu’aucun pays ou organisation ne peut relever seul.

  • Aucune vision ou stratégie ne saurait être élaborée en tant que déclaration d’une seule organisation sur la façon dont les choses devraient être.
  • Pour qu’un tel manifeste ait un sens, il faut la participation et la contribution de ceux qui sont en première ligne de la santé mondiale, dans le cadre d’un dialogue avec les dirigeants internationaux, régionaux et nationaux.

C’est pourquoi nous vous invitons à donner vie et forme à ce Manifeste, et à rejoindre les plus de 10,000 membres du Mouvement pour la vaccination à l’horizon 2030 dont l’action et la réflexion ont été sources d’inspiration du Manifeste.

Le manifeste a d’abord été diffusé sous la forme d’un numéro spécial de The Double Loop (La Double Boucle), le bulletin de l’Unité de recherche de la Fondation. Pour en savoir plus…

Jazz ensemble or classical orchestra

Metaphors of global health: jazz improvisation ensemble or classical orchestra?

Reda SadkiCulture, Global health, Thinking aloud

In the realm of classical music, the orchestra stands as a formidable emblem of aesthetic grandeur and refinement. However, beneath the veneer of sophistication lies a deeply entrenched system that stymies the potential for creative exploration and spontaneity. As in a straitjacket, the rigidity of this system threatens to reduce the rich tapestry of human experience into a sterile hierarchy, devoid of the serendipity that breathes life into artistic expression.

The classical orchestra is governed by a hierarchy that places the conductor at the apex, wielding an almost tyrannical authority over the musicians. It is a system that perpetuates a culture of conformity, where musicians are coerced into subsuming their individuality in the service of an imposed order. This stifling environment leaves little room for the musicians to contribute their own interpretations or creative impulses, and instead demands that they adhere strictly to the conductor’s vision, which is often based on a prescriptive reading of the composer’s intent.

The result is a musical experience that is reductive in nature, an experience that is stripped of the chaos and unpredictability that are essential to the vitality of artistic expression. In its quest for order, the classical orchestra neglects the potential for serendipity, which can arise from the unscripted interplay of individual talents and the embrace of the unexpected. By eschewing the possibility of chance encounters and emergent beauty, the orchestra constricts the wellspring of creative potential, relegating the musicians to mere cogs in a mechanistic apparatus.

Furthermore, the insistence on a strict adherence to the conductor’s interpretation perpetuates an illusion of coherence and stability that belies the complexities of the human experience. The orchestral structure does not allow for the acknowledgement of discord and dissonance that are inherent in life. Rather, it seeks to impose a singular vision of order, relegating the multitudes of voices and perspectives to the margins of the performance.

In the end, the classical orchestra emerges as an antiquated institution that, in its blind pursuit of order, risks smothering the creative spirit that animates the very essence of artistic expression. It is a system that demands submission and conformity at the expense of individuality and exploration. By refusing to acknowledge the serendipity and complexity that lie at the heart of human experience, the classical orchestra risks becoming a hollow shell, a lifeless relic of a bygone era that has yet to fully grasp the true potential of the human spirit.

Is global health more like a classical orchestra or jazz improvisation?

In a dimly lit club, a hazy smoke fills the air, while the soft murmur of conversation weaves its way through the room. Then, the jazz ensemble erupts in a mesmerizing explosion of sound – an intoxicating mix of chaos and order, each musician adding their own unique twist to the shared melody. As their improvisation unfolds, the music becomes a living, breathing entity, transcending the boundaries of the individual instruments.

This vibrant expression of creativity and spontaneity form the improvisational spirit. Could embracing the fluidity and adaptability inherent in jazz as a metaphor help us rise to meet the myriad challenges that crop up in our quest to improve the health of people across the globe?

The notion of orchestrating global health initiatives like a classical ensemble, with a conductor dictating every note and movement, might be appealing at first glance. But the diverse and interdependent nature of global health demands that we adopt a more inclusive approach that values flexibility, adaptability, and collaboration. Just as a jazz ensemble thrives on its ability to respond to the unexpected, global health initiatives must be nimble enough to adjust to the constantly shifting realities on the ground.

It’s a world where the unexpected reigns supreme, where musicians effortlessly dance between moments of chaos and harmony. In this realm of improvisation, there’s a certain magic that takes hold – a power that transcends the limits of scripted notes and carefully crafted melodies.

The power of improvisation lies in its ability to tap into the uncharted territories of human creativity. It’s a process that relies on a deep sense of trust and vulnerability between the musicians, who must be willing to venture into the unknown, guided by nothing more than their intuition and their shared connection to the music. As they navigate this uncertain terrain, the musicians become explorers of a musical landscape that is constantly shifting and evolving, and in doing so, they discover new possibilities and pathways that would have otherwise remained hidden.

Improvisation also fosters a unique form of communication, one that transcends the boundaries of language and culture. In the midst of a jazz jam session, the musicians engage in a conversation that is at once wordless and profound, speaking to one another through the language of their instruments. As each musician adds their own voice to the collective melody, they create a tapestry of sound that tells a story – a story that is rich in emotion and nuance, and that speaks to the universal human experience.

Moreover, improvisation has the power to challenge and transform our understanding of what is possible. By breaking free from the constraints of traditional structures and forms, improvisation invites us to question the status quo and to reimagine the world in new and exciting ways. It teaches us to embrace uncertainty and change, and to see the beauty in the unexpected. In this sense, improvisation serves as a potent reminder of the boundless potential that lies within each of us, waiting to be unleashed.

As the haunting strains of a saxophone solo rise and fall, and the pulse of the bass line echoes through the dimly lit club, the power of improvisation is laid bare for all to see. It’s a force that defies categorization, and yet it holds within it the capacity to move and inspire, to challenge and transform. In the ever-changing world of jazz, the power of improvisation is the lifeblood that courses through the music, and it’s a force that, if harnessed, can open up new worlds of possibility and wonder.

In this context, the jazz ensemble emerges as the more fitting metaphor. By incorporating the principles of complexity and change found within the jazz improvisation, we can more effectively navigate the challenges that come with addressing global health issues. It is through this adaptable and collaborative approach that we can truly accelerate progress and create lasting, meaningful change.

So, as the last notes of the saxophone linger in the air and the final beats of the drums echo through the club, we’re reminded of the power and potential of improvisation. It’s a lesson that, if taken to heart, might help transform our efforts to improve global health and the lives of those we seek to help.

Is global health more like a classical orchestra or a jazz improvisation ensemble? Which should it be in the future?

A bunch of hot air

Rising together: promoting inclusivity and collaboration in global health 

Reda SadkiGlobal health

The ways of knowing of health professionals who work on the front lines are distinct because no one else is there every day. Yet they are typically absent from the global table, even though the significance of local knowledge and action is increasingly recognized. In the quest to achieve global health goals, what value should professionals within global health agencies ascribe to local experience? How do we cultivate a more inclusive and collaborative environment? And why should we bother?

A recent roundtable discussion, attended by technical officers and senior leaders, provided an occasion to present and explain how the Geneva Learning Foundation’s Immunization Agenda 2030 (IA2030) platform and network could be used to support “consultative engagement” between global and local leaders. This platform and network is reaching over 50,000 health professionals, helping them build connections with each other – defying boundaries of geography and health system levels – to transform learning into action. 

One global observer expressed concern that all this learning, sharing, and action might be “a bunch of hot air”. This can, at best, be interpreted as doubt towards the value of lived experience, and, at worst, as a brutal dismissal of the will and commitment expressed by thousands of health professionals working, more often than not, in difficult circumstances.

How should we understand and respond to such skepticism?

Between March and September 2022, 10,000 health professionals working on the frontlines of immunization made a personal, moral commitment to making a difference in their communities, above and beyond their professional roles. Together, they decided to make their country’s commitment to IA2030 a personal and professional commitment – because they wanted to. This cannot be insignificant.

In the first year of our IA2030 programme, we observed remarkable gains from such peer learning in the confidence and self-esteem of participants. It has already led to a year of intense sharing of experience, leading to over one thousand health professions taking corrective actions to tackle the root causes of their local challenges, using their own local resources and capacities, and sharing challenges, successes, and lessons learned. Such higher-order learning in the affective domain has already been shown to support deepening competencies needed to tackle complex problems.

To overcome current immunization challenges, it may be useful to first recognize the value of diverse perspectives, acknowledging that each individual’s lived experience can provide unique insights and knowledge. Building meaningful, respectful connections to those on the frontlines creates new possibilities for how this can be combined with the world’s collective knowledge: the norms, standards, and other guidelines that global agencies produce. By doing so, we can create a more inclusive culture, ensuring not only that every voice is heard and valued, but that these voices combine to figure out the “how” of solving global health challenges that play out at the local level.

Moreover, we must avoid perpetuating self-fulfilling prophecies that could undermine the motivation and participation. Heat generated by the voices and collective commitment of thousands of local health workers mobilizing and learning together to take action will evaporate into thin air if the global community fails to listen, respond and support them. A less cynical, more inclusive approach might help us raise the upswell of support in favor of immunization. It is essential that we encourage active involvement and recognize the dedication of those who strive to make a difference in the communities they serve. By fostering a supportive environment when we sit at a global roundtable, we can help dispel skepticism and promote the engagement of health professionals at all levels.

Lastly, it is important to challenge any biases or preconceived notions that may hinder our ability to appreciate the knowledge held by others. As we continue to advocate for local action and recognize the significance of local actors, we must be mindful of potential biases that could inadvertently devalue the contributions of those we seek to support. By being aware of these biases, we can work towards a more equitable global health community where everyone’s knowledge and experience are valued.

Promoting inclusivity and collaboration in global health agencies is critical to achieving our shared objectives. By recognizing the value of local perspectives, challenging biases, and promoting active engagement, we can create a more supportive environment for health professionals around the world and ensure that their collective efforts are recognized and supported.

It is important to consider such rejection in the context of the growing emphasis on local action and the recognition of local actors within the global community. As we work towards a more inclusive and collaborative environment, we must ensure that we genuinely appreciate and support local efforts.

Credible knowers

Credible knowers

Reda SadkiGlobal health, The Geneva Learning Foundation, Thinking aloud

“Some individuals are acknowledged as credible knowers within global health, while the knowledge held by others may be given less credibility.” – (Himani Bhakuni and Seye Abimbola in The Lancet, 2021)

“Immunization Agenda 2030” or “IA2030” is a strategy that was unanimously adopted at the World Health Assembly in 2020. The global community that funds and supports vaccination globally is now exploring what it needs to do differently to transform the Agenda’s goal of saving 50 million lives by the end of the decade into reality. Last year, over 10,000 national and sub-national health staff from 99 countries pledged to achieve this goal when they joined the Geneva Learning Foundation’s first IA2030 learning and action research programme. Discover what we learned in Year 1… Learn more about the Foundation’s platform and network…

In global health, personal experience is assumed to be anecdotal, the lowest form of evidence. We are learning, as one of many organizations contributing to Immunization Agenda 2030 (IA2030), to reconsider this assumption.

An ongoing ‘consultative engagement’ in which a group of global experts has been listening and learning with health professionals working in districts and facilities provides a practical example that changing how we know can lead to significant change in what we do – and what results and outcomes may come of it.

On 12 December 2022, the Geneva Learning Foundation (TGLF) hosted a special event with the Immunization Agenda 2030 Working Group on Immunization for Primary Healthcare and Universal Health Coverage, which includes representatives from leading global agencies that support immunization efforts worldwide. 

Over 4,000 people participated. Most were health workers from districts and health facilities in Asia, Africa, and Latin America. In the run-up to the event, they shared 139 context-specific experiences about their daily work – challenges, lessons learned, and successes – in integrating immunization as part of primary health care practices. The live event opened with such stories and then transitioned into a formal presentation of the framework. This helped everyone make sense of both the “why” and the “how” of the new framework.

However, this was not the first time that the global group was in listening mode. In fact, the new framework was the capstone in a year-long ‘consultative engagement’ that had begun at Teach to Reach 4 on 10 December 2021, attended by 5,906 health professionals who deliver vaccines in districts and facilities. (Teach to Reach is the Foundation’s networking event series, during which participants meet to share experience and global experts listen and learn. You can view the sessions on primary health care here and here.)

Global health organizations often issue new frameworks and guidance, sometimes accompanied by funding for capacity development. However, dissemination often relies upon conventional high-cost, low-volume approaches, such as face-to-face training or information transmission through digital channels, even though fairly definitive evidence suggests severe limitations to their effectiveness.

To address these challenges, the Geneva Learning Foundation and its partners are launching the IA2030 Movement Knowledge to Action Hub, a platform for sharing local expertise and experience across geographical and health system level boundaries. The goal is to research and implement new ways to convert this knowledge into action, results and, ultimately, impact.

The Double Loop, a monthly insights newsletter edited by Ian Steed and Charlotte Mbuh, is one component of this Hub. The newsletter asked questions to all 4,000 participants of the December 2022 event, 30 days and 90 days later, to gather feedback on the new framework.

Here are the questions we asked three months on:

  1. Since you discovered the Framework for Action: Immunization for Primary Health Care, have you referred to this framework at least once? If you have not used it, can you tell us why? How could this Framework be improved to be more useful to you?
  2. If you have referred to this Framework, tell us what did you do with the information in the Framework? How did your colleagues respond to the Framework?
  3. How did this Framework make a difference in solving a real-world problem you are facing? How did things turn out? Explain what you are doing differently to integrate health services, empower people and communities, and lead multisectoral policy and action.

Within days, we received hundreds of answers:

  • Some health professionals apologized, often citing field work, emergency response, and other pressing priorities. This can help better understand the strengths and weaknesses of learning culture (the capacity for change), which the Foundation’s Insights Unit has been researching in the field of immunization since 2020.  
  • Others praised the framework in generic terms (“It’s a great framework”), but did not share any specific examples of actual review, use, or application. Some speak to sometimes peculiar practices of accountability in immunization, where top-down hierarchies remain the norm and provide incentive to always provide positive accounts and responses, whatever the reality may be.
  • A few respondents candidly explained that the Framework does not fit their local needs, as it was primarily designed for national planners. This begs the question of how such local adaptation and tailoring might happen.
  • Finally, we discovered credible, specific narratives of actual use, including adaptation at the local levels. These provide fascinating examples of how a global guidance, developed through a year-long consultative engagement, is actually being translated into practice.

Our Insights Unit is analyzing these narratives, as this exercise is helping us learn how to scale the IA2030 Movement Knowledge to Action Hub to involve the more than 10,000 health professionals who joined the Movement in its first year.

The Double Loop regularly shares feedback from its readers as “insights on sights”. You can already read a sample of responses about the framework.

On 31 March 2023, our team will meet with the IA2030 Working Group to share and discuss the insights gathered through this process.

The Working Group has also changed through this process. In January 2023, it invited its first sub-national member, Dr. María Monzón from Argentina, who brings her own professional experience and expertise from running a primary health care center. She will also serve as the voice of over 10,000 Movement Leaders, immunization staff from 99 countries and all levels of the health system, who met and have been intensively collaborating for over a year in the Foundation’s IA2030 programme. 

Surprisingly, one global immunization technical expert shared his concern that thousands of professionals learning from each other to strengthen their resolve and action might amount to “just a bunch of hot air”. This will only be the case if the global immunization community fails to respond and support, even as it proclaims a genuine willingness to recognize local voices as credible knowers. In another blog post, I’ll share some thoughts on what it might take to rise together.

Overcoming barriers to vaccine acceptance in the community: Key learning from the experiences of 734 frontline health workers

What works in practice to build vaccine confidence?

Reda SadkiGlobal health

This is the content of a poster presented today by The Geneva Learning Foundation (LinkedIn | YouTube | Podcast | Twitter)  at the International Social and Behavior Change Communication Summit 2022 (#SBCCSummit) held 5-9 December 2022 in Marrakech, Morocco. What is the Geneva Learning Foundation? Get the full report… Read the preface by Heidi Larson…

From responding to the initial shock of the pandemic to preparing COVID-19 vaccine introduction

Over 6,000 health professionals joined the COVID-19 Peer Hub in July 2022, part of the Geneva Learning Foundation’s (TGLF) global immunization learning-to-action platform.

  • From August to October, they focused on developing and implementing recovery plans.
  • In November 2020, members of the COVID-19 Peer Hub decided to launch a reflective exercise to prepare COVID-19 vaccine introduction, after three months on early recovery implementation.
  • The exercise took place between 9 November and 18 December 2020.

We asked a simple question: Can you think of a time when you helped an individual or group overcome their initial reluctance, hesitancy, or fear about vaccination?

  • Each participant developed a case study to describe and analyze such a situation.
  • They then peer reviewed each other’s case studies, giving and receiving feedback to learn from each other.

Who participated?

Local practitioners from 86 countries:

  • 81% (n=591) in West and Central Africa
  • 11% (n=80) in Eastern and Southern Africa
  • 6% (n=43) in South Asia

Health system levels:

  • 18% (n=131) national
  • 29% (n=213) sub-national
  • 29% (n=214) district
  • 20% (n=144) facility

So what?

What was the significance of the experience for participants?

Transformation: “I can tell you this experience changed my life. It has changed my practice and made me think differently about the way I work, considering things I did not think about before.”

Defying boundaries: “It was a opportunity like I have never had before… I have studied with peer from my country. Having a lot of people from other countries sharing their experience was something else.”

What we learned from local practice

  1. Vaccine hesitancy is a complex problem that blanket recommendations or prescriptive guidelines are unlikely to solve.
  2. Instead, we should strive to recognize that solutions must be local to be effective, leveraging the ability of local staff to adapt to their context in order to foster confidence and acceptance of vaccines.
  3. Supporting health workers, already recognized as trusted advisors to communities, requires new ways of listening and learning.
  4. It also requires new ways of fostering, recognizing, and supporting the leadership of immunization staff who work at the local level under often difficult conditions.

4 targeted intervention approaches that worked

  1. targeted individual counselling at the individual or household level;
  2. community outreach for larger groups;
  3. formal meetings (usually for community and religious leaders); and
  4. organized training sessions in which particular subgroups were involved (e.g., training for religious teachers, health workers, youth groups, women’s groups).

2 key determinants that changed minds and behaviors

  1. The tone and delivery of the interventions were as critical to the success of the immunization as the activities themselves.
  2. The positive effect of using multiple approaches: high degree of understanding and compassion; navigating sensitive dynamics, grieving families, and issues related to vulnerable communities affected by displacement or war.

Anthrologica performed the qualitative analysis of the case studies and developed the report for the Geneva Learning Foundation.

Heidi Larson: “So much remains determined by the capacity of people on the frontlines to explain, advocate, and respond in ways that are almost entirely dictated by context”

Reda SadkiGlobal health

This is the preface by Heidi Larson for the report “Overcoming barriers to vaccine acceptance in the community: Key learning from the experiences of 734 frontline health workers”. This report is presented today by The Geneva Learning Foundation (LinkedIn | YouTube | Podcast | Twitter) at the International Social and Behavior Change Communication Summit 2022 (#SBCCSummit) held 5-9 December 2022 in Marrakech, Morocco. What is the Geneva Learning Foundation? Get the full report… Read the preface by Heidi Larson…

My own consciousness of the fragile equilibrium sustaining vaccine confidence came from working with immunization programmes and local health workers to defuse rumors that threatened to derail vaccination initiatives. Twenty years ago, this meant traveling to countries to meet, build relationships with, and work side-by-side with frontliners.

Since that time, the corpus of research on the topic has grown tremendously. Elaborate behavioral science frameworks, supported by robust monitoring and evaluation, are now available to guide policy makers, donors, and other decision makers, for those who have the time and resources to implement them. 

Nevertheless, there remains a gap in our understanding of how the complex dynamics of change actually happen, especially at the most local levels. For this we need to listen to the local experiences and voices of those at the front lines who can tell the real-life stories of how these complex dynamics are navigated.

I found the idea of this report fascinating: 734 health professionals from all levels of the health system took time out from their demanding daily duties to reflect on their practice, describing and then analyzing a situation in which they successfully helped an individual or a group accept or gain confidence that taking vaccines would protect them from disease. Furthermore, they did this during four weeks of remote collaboration at a very crucial historical moment, months before the first doses of COVID-19 vaccine were to arrive in Ghana and Côte d’Ivoire.

Reading this report, I experienced a sense of discovery. The stories shared reminded me of my early work with colleagues working at the local levels, and gave me renewed appreciation of   these health professionals who faced even greater challenges in the face of a deadly pandemic. I could feel how hard it is to remain that ‘most trusted adviser’ to communities, and how so much remains determined by the capacity of people on the frontlines to explain, advocate, and respond in ways that are almost entirely dictated by context, in this case a highly uncertain and evolving pandemic.

I could also feel the tensions due to the imperfection of a participatory methodology that did not neatly fit the conventions and norms of expert-led research. Conventional research has seldom been able to access such local narratives, and even less so with such a large and diverse sample. Furthermore, the peer learning methodology used by the Geneva Learning Foundation meant that there was an immediate benefit for participants who learned from each other. Rather than research subjects or native informants, case study authors were citizen scientists supporting each other in the face of a common challenge. The scale, geographic scope, and diversity of contexts, job roles, and experiences are also strengths of this work. 

Supporting health workers, already recognized as trusted advisors to communities, requires new ways of listening, new ways of supporting, new ways of measuring, documenting and learning.

It also requires new ways of recognizing the leadership of immunization staff who work at local levels under often difficult conditions. 

In some cases, it may actually be the lack of prescriptive guidelines that enabled local health staff to draw on their own creativity and problem-solving capabilities to respond to community needs.

Rather than generalizations, we should therefore strive to recognize that solutions must be local to be effective, recognizing the ability of local staff to adapt to their context in order to foster confidence and acceptance of vaccines, and do all we can to support – letting them be the guide for future efforts.

Heidi Larson, PhD
Professor of Anthropology, Risk and Decision Science and
Founding Director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine

What is a rubric and why you should use it in global health education-small

What is a “rubric” and why use rubrics in global health education?

Reda SadkiGlobal health, Learning, Learning design, Theory

Rubrics are well-established, evidence-based tools in education, but largely unknown in global health.

At the Geneva Learning Foundation (TGLF), the rubric is a key tool that we use – as part of a comprehensive package of interventions – to transform high-cost, low-volume training dependent on the limited availability of global experts into scalable peer learning to improve access, quality, and outcomes.

The more prosaic definition of the rubric – reduced from any pedagogical questioning – is “a type of scoring guide that assesses and articulates specific components and expectations for an assignment” (Source).

The rubric is a practical solution to a number of complex issues that prevent effective teaching and learning in global health.

Developing a rubric provides a practical method for turning complex content and expertise into a learning process in which learners will learn primarily from each other.

Hence, making sense of a rubric requires recognizing and appreciating the value of peer learning.

This may be difficult to understand for those working in global health, due to a legacy of scientifically and morally wrong norms for learning and teaching primarily through face-to-face training. The first norm is that global experts teach staff in countries who are presumed to not know. The second is that the expert who knows (their subject) also necessarily knows how to teach, discounting or dismissing the science of pedagogy. Experts consistently believe that they can just “wing it” because they have the requisite technical knowledge. This ingrained belief also rests on the third mistaken assumption: that teaching is the job of transmitting information to those who lack it. (Paradoxically, the proliferation of online information modules and webinars has strengthened this norm, rather than weakened it).

Indeed, although almost everyone agrees in principle that peer learning is “great”, there remains deep skepticism about its value. Unfortunately, learner preferences do not correlate with outcomes. Given the choice, learners prefer sitting passively to listen to a great lecture from a globally-renowned figure, rather than the drudgery of working in a group of peers whose level of expertise is unknown and who may or may not be engaged in the activities. (Yet, when assessed formally, the group that works together will out-perform the group that was lectured.) For subject matter experts, there can even be an existential question: if peers can learn without me, the expert, then am I still needed? What is my value to learners? What is my role?

Developing a rubric provides a way to resolve such tensions and augment rather than diminish the significance of expertise. This requires, for the subject matter expert, a willingness to rethink and reframe their role from sage on the stage to guide on the side.

Rubric development requires:

  1. expert input and review to think through what set of instructions and considerations will guide learners in developing useful knowledge they can use; and
  2. expertise to select the specific resources (such as guidance documents, case studies, etc.) that will help the learner as they develop this new knowledge.

In this approach, an information module, a webinar, a guidance document, or any other piece of knowledge becomes a potential resource for learning that can be referenced into a rubric, with specific indications to when and how it may be used to support learning.

In a peer learning context, a rubric is also a tool for reflection, stirring metacognition (thinking about thinking) that helps build critical thinking “muscles”.

Our rubrics combine didactic instructions (“do this, do that”), reflective and exploratory questions, and as many considerations as necessary to guide the development of high-quality knowledge. These instructions are organized into versatile, specific criterion that can be as simple as “Calculate sample size” (where there will be only one correct answer), focus on practicalities (“Formulate your three top recommendations to your national manager”), or allow for exploration (“Reflect on the strategic value of your vaccination coverage survey for your country’s national immunization programme”).

Yes, we use a scoring guide on a 0-4 scale, where the 4 out of 4 for each criterion summarizes what excellent work looks like. This often initially confuses both learners and subject matter experts, who assume that peers (whose prior expertise has not been evaluated) are being asked to grade each other. It turns out that, with a well-designed rubric, a neophyte can provide useful, constructive feedback to a seasoned expert – and vice versa. Both are using the same quality standard, so they are not sharing their personal opinion but applying that standard by using their critical thinking capabilities to do so.

Before using the rubric to review the work of peers, each learner has had to use it to develop their own work. This ensures a kind of parity between peers: whatever the differences in experience and expertise, countries, or specializations, everyone has first practiced using the rubric for their own needs.

In such a context, the key is not the rating, but the explanation that the peer reviewer will provide to explain it, with the requirements that she provides constructive, practical suggestions for how the author can improve their work.

In some cases, learners are surprised to receive contradictory feedback: two reviewers give opposite ratings – one very high, and the other very low – together with conflicting explanations for these ratings. In such cases, it is an opportunity for learners to review the rubric, again, while critically examining the feedbacks received, in order to adjudicate between them. Ultimately, rubric-based feedback allows for significantly more learner agency in making the determination of what to do with the feedback received – as the next task is to translate this feedback into practical revisions to improve their work. This is, in and of itself, conducive to significant learning.

Learn more about rubrics as part of effective teaching and learning from Bill Cope and Mary Kalantzis, two education pioneers who taught me to use them.

Image: Mondrian’s classroom. The Geneva Learning Foundation Collection.