International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
BMJ Glob Health. 2021 Aug;6(8). doi: 10.1136/bmjgh-2021-006002.
The debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separatelyfrom the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time.
We constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011-2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication.
Pursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise.
It benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate. .
关于垂直规划（包括大规模疫苗接种）对卫生系统的影响的争论由来已久，且往往存在两极分化。研究已经分别评估了特定垂直卫生规划对卫生系统的影响及其本身的垂直规划目标。此外，这些卫生系统的影响通常被归类为积极或消极。然而，卫生系统实际上是复杂的、动态的和紧密相连的。系统各要素之间的关系决定了方案和系统层面的结果随时间的推移。
我们从两个定性数据集出发，通过归纳法构建了大规模脊髓灰质炎疫苗接种运动与埃塞俄比亚、印度和尼日利亚政府卫生系统之间相互作用的因果关系图。第一个数据集是在 2011-2012 年对这些国家的政策制定者、官员和一线工作人员进行的 175 次访谈。第二个数据集是在 2019 年对类似人群进行的 101 次访谈，重点是从根除脊髓灰质炎中吸取的经验教训。
在追求高疫苗接种覆盖率的过程中，如果不考虑疫苗接种运动对卫生系统的动态影响，那么在薄弱的卫生系统中，随着时间的推移，疫苗接种运动的覆盖率会不断提高，这些系统中有许多疫苗接种运动。随着时间的推移，频繁的疫苗接种运动通过并行结构产生的系统影响导致一线工作人员的积极性下降，疫苗接种犹豫的人群增加。联合提供干预措施有助于减轻这些负面影响。在疫苗接种运动较少的较强卫生系统中，这些问题没有出现。
垂直规划从减少并行系统的构建和尽可能地追求联合干预措施的提供、考虑一线工作人员的工作流程方面获益。最终，为了使卫生运动设计有效，它们必须符合提供和接受运动干预措施的人员的意愿，并且必须考虑到它们所运作的卫生系统的复杂、适应性本质。
