Sustainable Health Futures: Building Adaptability and Durability in Public Health Research Investments

Authors: Baldeep K. Dhaliwal, Aastha Kant, Rajeev Seth, Yawar Qaiyum, Vijayluxmi Bose, Kayur Mehta, Anita Shet

Ms. Baldeep K. Dhaliwal and Dr. Aastha Kant co-led this piece as researchers at the Johns Hopkins International Vaccine Access Center as part of the ARISE Project. Dr. Rajeev Seth, Mr. Yawar Qaiyu, and Ms.Vijayluxmi Bose, researchers from Bal Umang Drishya Sanstha, and Dr. Kayur Mehta and Dr. Anita Shet of Johns Hopkins International Vaccine Access Center, supported the development of this blog. For any questions, please reach out to : Ashet1@jhu.edu

Public Health Funding

The COVID-19 pandemic not only impacted the health and livelihoods of people around the world, it also shed light on current health investment gaps. Traditionally, health interventions end with project funding, most recently seen in the case of projects that were implemented to support communities in the wake of the pandemic. Reactionary approaches to project funding, without planning for the long-term utility of health investments, is an unsustainable approach. Public health interventions must, instead, prioritize long-term community needs in a way that facilitates community ownership over interventions and investments. A critical way to do so is by co-creating solutions with the commuity, driven by community needs, and grounded in creating long-lasting health investments. Below, we describe a case study that highlights the importance of identifying community needs, and ensuring long-term sustainability of investments to address identified gaps.

Establishing communuity ownership over new health interventions

Researchers from Bal Umang Drishya Sanstha (BUDS), an India-based organization, and from the International Vaccine Access Center (IVAC) at Johns Hopkins Bloomberg School of Public Health (JHSPH), implemented a project on immunization support that emphasized long-lasting solutions. In this formative research project, the Community Health Worker-Led Intervention for Vaccine Information and Confidence (CIVIC) Project, we leveraged community-based participatory research to involve the community from conception to implementation of an intervention to facilitate vaccine acceptance in Nuh District in Haryana State, India. Through the development of a community accountability board (CAB) and two human-centered design workshops, our team established local barriers and facilitators to childhood vaccination, and co-created a six-pronged vaccine uptake intervention with community leaders and community health workers. In the evaluation of this project, local community leaders highlighted the importance of leveraging community-driven approaches, as well as creating long-term solutions to address the systematic issues that are at the root of vaccine uptake issues. Lessons from the CIVIC Project laid the groundwork for implementing a project that invested in creating long-lasting solutions to vaccine uptake in Nuh, Haryana.

Project Setting

Estimates from the National Family Health Survey-5 conducted in 2019-21, suggest that only 53.8% of children under two years of age in Nuh were fully immunized. This situation was further exacerbated by the COVID-19 pandemic, due to lockdowns, poor outreach, and limited human resources. The National Health Mission’s health management and information system reported a substantial decrease in routine immunization services relative to the previous year, indicating that in March 2020 between 100,000 – 200,000 children missed their BCG and pentavalent vaccines, respectively⁴.

Vaccination Knowledge Hubs: A Case Study

Between November 2021 and February 2022, the BUDS-JHSPH team aimed to continue to build on CIVICs’ lessons in Nuh District. We used project funding to support the creation of two “Vaccination Knowledge Hubs” (VKH), to serve as long-lasting health educational centers. In designing these VKHs, we aimed to use community-driven approaches, while targeting the root of vaccine uptake issues, to address low vaccine uptake in Nuh. The VKHs had a catchment zone of ten villages across the district, and they were designed with strong support from local community leaders, including the sarpanch (elected village council head). Moreover, our team ensured that the building and infrastructure were flexible enough to adapt to the changing needs of the community, so as community needs evolved, the building could be re-purposed to support them.

The VKHs served as knowledge repositories and training centers where community members were able to access health pamphlets, meet health workers to answer vaccination and other questions, attend plays advocating for vaccines, attend BUDS-led trainings on vaccine advocacy strategies. The VKH also served as a center for dissemination of videos on the importance of immunization, conducting meetings, and lecture-demonstrations for various community mobilizers.

Our team further identified 20 young adults from these villages who were motivated to become ‘community champions’ for the VKH. These champions leveraged the VKH platform to gain knowledge on the importance of vaccines, identify ways to address misinformation, learn effective community mobilization strategies, and advocate for immunization as a child right. They co-created slogans, made posters, and planned social and behaviour change communication activities to attract people in hard-to-reach and marginalized areas of Nuh’s villages. The commmunity champtions further supported frontline health workers with immunization outreach in advance of ‘Village Health Sanitation and Nutrition Days’. These activities were conducted to support and align with the goals of the National Health Mission and Integrated Child Development Services.

Adaptability of the Vaccine Knowledge Hub

As vaccination rates began to rise in Nuh, and as project funding came to a close, the research team in collaboration with local community members examined approaches to capitalize on the VKHs’ adaptability to respond to community needs. Previous research with CAB members in the CIVIC Project had highlighted that providing women with education was essential to addressing the root of health issues, with one member stating in an interview that, “Girls over here are less educated or uneducated. If we focus on educating these girls then all these situations related to vaccination can be managed.”Building on the extensive available evidence that mothers’ education levels are directly proportional to health care-seeking behaviors for themselves and for their children, as well as for timely childhood immunization, and coupling this with our knowledge of community needs, our team continued to invest in the VKH platform.

We implemented a community-led project on introducing education efforts for adolescent girls and young mothers at the VKH. These educational sessions aimed to empower young girls and women to make informed health-related decisions for themselves and their children. Community champions initiated this project by identifying adolescent girls and young women aged 15- 25 years to participate in this program. The curriculum was designed to revolve around the Hindi language, functional mathematics, and themes to make girls aware about health, lifeskills, financial literacy, human rights and everyday life. Young women were centrally involved in discussions on the importance of nutrition, their children’s right to education and health, and menstrual hygiene. The program ultimately aimed to provide young women an opportunity to develop both Hindi and financial literacy; both prerequisites to empower women to take charge of their health and become effective decision-makers for themselves and their families.

As the VKH transitioned from a primarily vaccine education-based center to a broader educational platform for young women, we saw the tangible benefits of investing in capacity and infrastructure that could be tailored to community priorities. Enabling a vibrant and dynamic community-owned center that can grow and adapt to the evolving needs of the community, rather than establishing a short-term location with a singular focus, allowed the community to take a role in guiding the long-term direction of public health interventions based on needs.

Call for Action

Public health investments and interventions are frequently constrained in the creation of long-term, equitable collaborations with the community, focusing instead on short-term gains. This ‘parachute science’ approach with short-term investments sans long-term tangible benefits, can have negative effects for communities, their willingness to trust researchers, and their likelihood of continuing to engage in research. Moreover, public health funders and researchers have a moral imperative to facilitate capacity building, sustainability, and adaptability of investments. To drive long-term improvements in the community, community members must be able to directly feel and see the benefit of public health and research investments. Researchers would do well to shift from the overabundance of global initiatives focusing on short-term changes, and collectively work on strengthening public health infrastructure at, and beyond, the community-level.