Insights into vaccine hesitancy from systems thinking, Rwanda

Objective To investigate vaccine hesitancy leading to underimmunization and a measles outbreak in Rwanda and to develop a conceptual, community-level model of behavioural factors. Methods Local immunization systems in two Rwandan communities (one recently experienced a measles outbreak) were explored using systems thinking, human-centred design and behavioural frameworks. Data were collected between 2018 and 2020 from: discussions with 11 vaccination service providers (i.e. hospital and health centre staff ); interviews with 161 children's caregivers at health centres; and nine validation interviews with health centre staff. Factors influencing vaccine hesitancy were categorized using the 3Cs framework: confidence, complacency and convenience. A conceptual model of vaccine hesitancy mechanisms with feedback loops was developed. Findings/ A comparison of service providers' and caregivers' perspectives in both rural and peri-urban settings showed that similar factors strengthened vaccine uptake: (i) high trust in vaccines and service providers based on personal relationships with health centre staff; (ii) the connecting role of community health workers; and (iii) a strong sense of community. Factors identified as increasing vaccine hesitancy (e.g. service accessibility and inadequate follow-up) differed between service providers and caregivers and between settings. The conceptual model could be used to explain drivers of the recent measles outbreak and to guide interventions designed to increase vaccine uptake. Conclusion The application of behavioural frameworks and systems thinking revealed vaccine hesitancy mechanisms in Rwandan communities that demonstrate the interrelationship between immunization services and caregivers' vaccination behaviour. Confidencebuilding social structures and context-dependent challenges that affect vaccine uptake were also identified.

A Content Analysis of the Ghana National Health Insurance Scheme

Several African countries are contemplating the introduction of national health insurance and a few have already started implementing. It is a popular understanding among these countries that by moving away from fee-for-service to a system like national health insurance; the poor and marginalised who are most often the sickest will be protected. The issue of National Health Insurance (NHI) as an alternative health financing system was a popular option in Ghana. However; the desire for NHI and its popularity was not determined by a critical look at the technicalities involved in setting up such a system. Attention was not paid to the fact that the implementation of national health insurance is constrained by a country's economic; social and political context and the inherent technical limitations of health insurance. To determine feasibility in the context of existing constraints; detailed work ought to have been done on the administrative capacity available to technically design the scheme; manage the process and thereafter manage the schemes. Earnings especially of the informal sector; the collection of contributions and the existing health care infrastructure and the commitment and incentives for health providers to make such a complex system work needed equal attention. Careful assessment is critical in producing a policy that is not only desirable but also feasible. It is apparent that the reasoning behind the Ghana Scheme was more towards a general look at risk pooling and providing access by reducing the individual financial burden than a close look at cost containment; efficiency and sustainability