The Vaccine Trust - Pakistan - COVID19

Pakistan: Towards a Trust Framework Read more: www.thevaccinetrustproject.com 1

Towards a Trust Framework Purpose and agenda

Meeting purpose

To introduce ongoing work investigating the intersection of trust and COVID-19 vaccines and introduce emerging insights.

Through this, we hope to: • Gather input on other relevant ongoing work • Solicit feedback & discussion on emerging findings

Agenda 1. Context & process 2. Cross-country emerging trust framework 3. Building trust in Pakistan

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ASSESSING

TRUST

As the world enters its third pandemic year and the COVID-19 virus continues to circle through the global population, the ‘post-COVID’ world is becoming an increasingly unlikely reality

The COVID-19 pandemic has been a profound lesson on the future of public health in a globalized world – highlighting the interdependencies and needs for more resilient systems Exacerbation of existing and new inequities

Rapid cross-border spread

Divergent reactions across nations

Politicization of the pandemic response

…

This may well be the new reality – living with this virus, and being prepared to better deal with the next one as a global community

“Eradicating this virus right now from the world is a lot like trying to plan the construction of a stepping-stone pathway to the Moon. It’s unrealistic” Michael Osterholm, “The coronavirus is here to stay – here’s what that means,” Nature

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ASSESSING

TRUST

The COVID-19 pandemic – and the vaccination effort in particular – has inspired a great deal of thought around trust, resiliency, and the nature of the unspoken agreements that bind societies together

Trust is critical but often overlooked…

Trust is a critical component within efficient, well-functioning, sustainable health systems. It is strongly tied to accumulated experience – making each new interaction with a health system important for growing or maintaining trust.

And yet, as the pandemic has laid bare, trust can be a nebulous and overlooked area of public health.

“Trust is paramount to the delivery of health care…[but] trust is often taken for granted, leading to neglect in the ways to maintain and build it. In turn, this results in harm to the system”

…and is tightly linked with resiliency – driven by a strong social contract A recent piece in Nature, examined national COVID-19 responses across 84 countries worldwide through the lens of trust and found that trust is positively correlated with resilience of the health system and consequently a reduction in cases and deaths/capita.

The Nature authors stress that trust is a valuable component of any government’s response to the pandemic, along with adaptive responses to the stringency of government interventions. And they conclude that the variation in resilience to COVID-19 reflects, among other things, variation in the nature and strength of the ‘social contract’ across countries2.

Felix Gille, Journal of Health Services Research & Policy (1) 1.

2.

Gille F, Smith S, Mays N. Why public trust in health care systems matters and deserves greater research attention. J Health Serv Res Policy. 2015 Jan;20(1):62-4. doi: 10.1177/1355819614543161. Epub 2014 Jul 17. PMID: 25038059.

Lenton, T.M., Boulton, C.A. & Scheffer, M. Resilience of countries to COVID-19 correlated with trust. Sci Rep 12, 75 (2022). https://doi.org/10.1038/s41598-021-03358-w

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ASSESSING

TRUST

The social contract, in particular, has been the subject of much discussion in the global health landscape, as health – and vaccination in particular – represent one of the most concrete manifestations of this contract

“The social contract is the basic set of rules, norms, and mutual obligations that bind together individuals, firms, civil society, and the state. Simply put, the social contract defines what we owe each other” -

Minouch Shafik Project Syndicate (2022)

Vaccination represents a concrete test of the social contract…

…making an understanding of trust imperative for a resilient pandemic response

As the recently announced BMGF board member, Minouch Shafik, writes: vaccine hesitancy is a symptom of the primary malady of our age: a broken social contract, and the subsequent collapse of public trust in institutions.

As the COVID-19 crisis moves from a short to a longer-term crisis, many governments have responded to the pandemic with social protection policies to strengthen the social contract.

However, these quick interventions must be balanced with the longer-term sustainability of solutions.

Vaccination, given its foundation in the marriage of individual preferences and collective interests reflects the social contract. And it demonstrates that whether people follow social protection measures is not simply an epidemiological question – it is a social one.

Examining and assessing the impact of COVID-19 vaccinations on trust – in its multiple forms – will be an important step in building a more resilient global health system.

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ASSESSING

TRUST

While the countries studied are often referred to as ‘low-trust’ contexts, trust still plays a critical role in guiding decision-making and driving behaviours All three countries studied rank low in a global context on various trust indices, including perceived public sector corruption,1 regulatory quality, governmental effectiveness,2 etc.

But even in these ‘low trust’ contexts, we spoke with people from all walks of life who use trust to guide important decision-making.

Perception of Corruption 2020 global rank1 Kenya

124th

out of 179

Pakistan

125th

out of 179

Nigeria

149th

out of 179

“You won’t believe this, but since we started the company, we have not run a single ad… People that know me and trust me are the ones hiring us”

Trust is a dynamic concept that is constantly evolving as people interact with each other and their surroundings.

The key to understanding trust will be to characterize how different types of trust are built and how they relate to each other within societies.

– Lil Bill, 28, Entrepreneur from Kwara

1. Transparency International: Corruption Perceptions Index. 2. Worldbank: Worldwide Governance Indicators

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This investigation was carried out over four major steps – leveraging the wealth of existing knowledge on vaccine acceptance to frame a deep-dive into trust Lit Review & Expert Interviews Framing of research topics was driven by a literature (manual & automated) and expert interviews

Social Media & News Listening Social media & news media listening provided direction for particularly salient public narratives to explore

In-depth engagements with Pakistanis from a variety of low to low-middle income backgrounds, in 4 urban centers in collaboration with local organizations and individuals

17,500+ posts from Twitter, Facebook, Instagram, YouTube, forums, and blogs), collected June-August 2021

110+ engagements with respondents and their ecosystems (observations, deep dives, key informant interviews and focus groups)

40+ Internal BMGF & external expert interviews

200+ documents (academic, journalistic and organizational) hand-reviewed & 9,000 automatically reviewed for keywords & themes

Fieldwork

Analysis (ongoing) Analysis (ongoing) Findings from the previous steps are collectively examined to pull out themes and eventually build up to a trust framework

A 4-step process, which includes data mapping, clustering, member checking, and a final round of social media listening 7

ASSESSING

TRUST

Fieldwork: We conducted deep dives with respondents from different positions in Pakistani society providing us with multiple perspectives on trust and vaccine hesitancy Research locations in Pakistan Islamabad Rawalpindi

Recruitment criteria

People profiles

Age: Participants across generations

Community leader

were included Lahore

Gender: Equal representation of both women and men was ensured Karachi

Dhok Hassu (Rawalpindi) – Low income. Ethnically diverse with a notable Pashtun presence.

France Colony (Islamabad) – Majority Christian. Low income.

Ethnically diverse. Highly internationally connected Manzoor Colony (Lahore) – Middle to low income. Majority Punjabi. Gentrifying.

Bheer Pind (Lahore) – Middle to low income. Majority Punjabi.

Emporium Slums (Lahore) – Very low income. Ethnically diverse.

Socially insular.

Ibrahim Hyderi (Karachi) – Low income. Ethnically diverse.

Fishing community.

Kharadar (Karachi) – Middle to low income. Ethnically diverse.

Status: Individuals who hold different positions (with differing levels of power) within their communities were recruited, i.e.

• 1/3 middle to upper class • 1/3 lower middle class • 1/3 impoverished

e.g., religious leader, elder

Healthcare worker

e.g., doctor, LHW, vaccinator

Health service provider

e.g., traditional healer, midwife

Experience with COVID e.g., direct & care experience

Local business owner e.g., shop owner

Mobile community member

e.g., truck driver, taxi or rickshaw driver

Youth

e.g., college student, unemployed 8

ASSESSING

TRUST

We studied how trust plays out in peoples’ experience of the health system – which required defining ‘health systems’ according to how people understand and experience them: as holistic ideas, interconnected with larger systems People define health holistically, linking it to other areas of life such as wellbeing and financial success….

... And perceptions of the ‘health system’ are embedded in and explicitly related to other government interactions

“For instance, if a person wants to eat but can’t – he doesn't have the physical, emotional or financial strength – then the person is not healthy. Physically, maybe the person is sick and can’t eat. Emotionally, maybe the person is depressed or lonely and doesn’t have the appetite to eat, and financially if the person doesn't have the money to buy food to eat”

“The narrow streets, shabby infrastructure, drug addict youth, and poor sewerage system made me sick in the initial year. I still overthink a lot and pray to God to keep my son safe from this terrible environment”

– Alfa Sule, 50 (Ilorin), defines health as encompassing physical, emotional, and financial wellbeing

– Hania, 32, blames the poor conditions in France Colony (Islamabad) for various health issues 9

ASSESSING

TRUST

Fieldwork: A variety of research methods were used to provide a comprehensive understanding of communities studied Recruitment funnel Micro-conversations & Focus Groups

Observations

Informant Interviews

Deep dives

Interviewing fishermen in Ibrahim Hyderi

Observing a vaccination drive in Dhok Hassu

Interviewing a grocery store owner in Manzoor Colony

Deep dive with a domestic worker in Emporium Slums

10-15 minute conversations, as well as 1-2 hour focus groups, to gain entry points and quickly capture a broad range of opinions & perspectives

Staying at community or health sites to observe how people navigate their surroundings for up to several hours at a time

1-2 hour conversations with respondents from relevant profiles who provided key opinions on health, religion, politics, and more

Multi-hour engagements with participants in their homes, workplaces and communities to get not only what they say but also what they do

10 focus groups in health centers, ports, university campuses and more

10 observations including urban slums, hospitals, community deras, vaccinations sites

30 informant interviews, from busy health care providers to small business owners

35 deep dives, from mobile community drivers at work, to mothers in their homes 10

ASSESSING

TRUST

Our analysis highlights that trust broadly operates at two levels in the healthcare space: trust in the promises inherent in the social contract surrounding health and the delivery of that contract

T RU S T I N T H E

Promise

of the social contract

T RU S T I N T H E

Delivery

Of the social contract

Belief that the health system will uphold the social contract. This implied contract includes an emotional certainty in the goodwill and shared values of the systems surrounding health.

Belief that the health system is accessible, safe, and effective.

This trust relies on a cognitive understanding of the system’s competence, generally linked with past experiences.

Considerations which determine trust level:

Does the health system have my best interests at heart?

Do I believe that the vaccine has value for me?

Considerations which determine trust level:

Does the health system generally work for me?

Do I believe the vaccine is available & accessible to me?

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ASSESSING

TRUST

Each type of trust is linked with different types of health decisions – with the promise more closely linked with the social aspects of health decisions, while trust in delivery is linked the the practicalities of health

Trust in the promise drives desire to act

Tied to individual and collective life objectives

Trust in delivery drives ability to succeed

Tied to the practical reality of accessing healthcare

All health decisions impact people’s lives, and most have profound social implications. These implications are especially relevant when a vaccine touches deeply-held cultural priorities (e.g. fertility), or has the potential to impact others (e.g. the decision to vaccinate).

Healthcare decisions are also of course guided by people’s understanding of the basic mechanisms of health, e.g. how diseases are caused, managed or cured. This includes people’s understanding of how the health systems they interact with manage treatment and prevention efforts, and prioritize different populations.

Harryson (50, Nairobi), got vaccinated as a way to attract customers to his safari tour business…

… But he still felt the need to do extensive research to feel certain that the side-effects were not too harmful

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ASSESSING

TRUST

When either of these two types of trust is low or absent, vaccine uptake is hindered – with important implications for efficiency and cost necessary to drive action, and therefore impact on system resiliency A PAT H Y

AVO ID A N C E

UNCERTAI NT Y

Lack of trust in the promise drives apathy – and must be compensated for with large delivery investments.

Lack of trust in delivery results in avoidance – and must be compensated for with a compelling promise.

A lack of either type of trust leaves space for uncertainty – which is filled with both real concerns and rumors.

30% of US adults indicate they probably or definitely will not be vaccinated – and 42% of them list “Don’t think I need it” as a major reason (a possible proxy for apathy)1

In Kenya, 37% of those who are unvaccinated but want to get vaccinated perceive a lack of appointments2 as a major barrier – a real issue which also contributes to low trust

Lack of institutional trust has been linked to consumption of misinformation.3 In the UK, misinformation alone has been linked with a 6% decrease in intent4 to vaccinate.

When there is a deficit of one type of trust, the other must be high enough to compensate – increasing overall system cost to drive action.

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Case study: In all three countries studied, women are in danger of being left behind in the vaccination effort, expressing a trust deficit not only in delivery, but also in the COVID-19 vaccine promise

Women are often less vaccinated – and may also express less intention to vaccinate In Pakistan women represent just 38% of those who have received a first jab1 (September 2021). In Nigeria, male gender is positively correlated with willingness to vaccinate2. In Kenya, where actual vaccination rates are more equal3, unvaccinated women are less likely than men to get vaccinated in the future4.

Real and perceived practical access barriers decrease trust in delivery “There is a lady on the other side of the house who …won’t go back for the second jab because she is the breadwinner and does not want to be sick again, she can’t be sick.

At the moment I would not take a covid vaccine…because I am breastfeeding” - Lilly (32, Kisumu)

While for many women, trust in the promise is undermined by the feeling that the vaccine may not be relevant for them In all three contexts, vaccines are tied with mobility and with participation in the formal economy. Both narratives have the potential to alienate women, whose bodies may already be deprioritized.

“My wife is not vaccinated and it's not necessary for her yet because her mobility is restricted”

Closing the gender gap will require not only addressing access issues and side-effect concerns, but also building a promise which resonates more deeply with women E.g. narratives around family progress and shared community health may be particularly motivating for women – who generally play a larger role in local community development in many contexts studied.

- Hamoon (32, Lahore) 14

ASSESSING

TRUST

We looked at each type of trust in the context of the broader health system, and the specific COVID-19 response…

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

TRUST IN THE PROMISE…

TRUST IN THE DELIVERY….

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ASSESSING

TRUST

… and found that trust can be uniquely assessed in each of these quadrants, an analysis which highlights key areas of trust deficit within communities

… OF THE HEALTH SYSTEM

TRUST IN THE PROMISE…

…. OF THE COVID-19 RESPONSE

Low trust in the health system creates a starting point for how people assess new health interventions such as the COVID-19 response.

Experiences with the COVID-19 response will impact expectations of the health system over the longer term.

TRUST IN THE DELIVERY….

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ASSESSING

TRUST

This provides us with an emerging framework for measuring trust impact – for assessing and tracking the long- and short-term trust implications of health interventions like the COVID-19 pandemic response

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

TRUST IN THE PROMISE…

No trust

TRUST IN THE DELIVERY….

Measuring trust impact: a diagnostic tool for decision-makers With this tool decision-makers (e.g.

NGO’s, government actors, funders and donors) can (1) assess trust and investigate the short and long term implications of specific vaccines (e.g., the COVID-19 response) on people's level of trust and willingness to engage with the health care system and (2) track the short and long term effects of health initiatives on trust and willingness to engage with the HCS

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Case study: Using the framework for analyzing the long-term trust impact of vaccine mandates, we see how short-term vaccine interventions, while immediately effective, can undermine trust in the promise over time

Vaccine mandates remove the need for building trust in the promise, which can be an effective quick-fix for driving up vaccination rates Vaccine mandates various types (e.g. withholding government services, targeting professions) have been employed in each country studied – and in each case resulted in higher short term uptake.

E.g. Kenya, some of the highest vaccination numbers were seen after blanket vaccine mandates were introduced in December. In Pakistan, many people have been vaccinated to avoid looming government threats (e.g. a rumored cell service cut-off). In both cases, increased update was not correlated with increased desire for vaccination.

Over the long-term, however, they begin to undermine trust in the promise of the overall health system – with clear impacts on system resilience

Effective mandates are highly targeted and implemented over short periods – and paired with extremely high vaccine access

For many, mandates introduce an element of suspicion which lingers over time.

Mandates seem to cause less consternation when the goal and underlying logic are clear. E.g. healthcare worker mandates – though they can also provoke pushback when the underlying promise remains unclear – are generally easier to understand than mandates on the broader public (and have been effective in other contexts, e.g. driving flu vaccine uptake2).

“Enforcing it makes the vaccine look shady. If you have to force it down my throat, there must be something wrong with it” - Little Bill (28, Kwara)

A recent investigation into trust in a COVID-19 context also linked mandates (“stringent government interventions”) to reduced system resilience, especially when they are implemented for a sustained period of time1.

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ASSESSING

TRUST

Each area within the trust framework can be defined by a key question capturing an aspect of how the system – and specific vaccines – are experienced

TRUST IN THE PROMISE…

TRUST IN THE DELIVERY….

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

Does the health system have my and my community’s best interests at heart?

Do I believe that this vaccine has value for me and my community?

Does the health system generally work for me and my community?

Do I feel this vaccine is available & accessible to me and my community?

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TRUST

And each key question can be further subdivided into key components of this personal experience – which can eventually be linked to concrete KPIs … OF THE HEALTH SYSTEM

TRUST IN THE PROMISE…

TRUST IN THE DELIVERY….

PI K NT ER ME D TH P E R L O IR FU VE QU E D RE

ASSESSING

…. OF THE COVID-19 RESPONSE

Does the health system have my and my community’s best interests at heart?

Do I believe that this vaccine has value for me and my community?

Sub-questions & emerging KPIs: • Do people feel like the system cares about their wellbeing?

• Do people feel like the interaction is transactional or relational?

• …

Sub-questions & emerging KPIs: • What goals does this vaccine help people achieve?

• Do people feel they have the agency to choose this vaccine?

• …

Potential KPIs: elements of the Public Trust in Health Care survey (PTHC) (Straten et al. (2002)), balance of public and private care

Potential KPI: elements of the Johns Hopkins COVID-19 Behaviors dashboard (e.g. percentage of unvaccinated who choose ‘I don’t believe I need a vaccine’), presence of mandates

Does the healthcare system generally work for me and my community?

Do I feel this vaccine is available & accessible to me and my community?

Sub-questions & emerging KPIs: • Do people feel they can get care without unsustainable strain on their resources?

• Do people know how to navigate the system?

• …

Sub-questions & emerging KPIs: • Do people perceive this vaccine as safe for them?

• Do people feel they can practically access it?

• Do people know how to learn more?

• …

Potential KPIs: “In the city or area where you live, are you satisfied or dissatisfied with the availability of quality health care?” (Gallup world poll), national and household-level healthcare expenditure

Potential KPIs: elements of the Johns Hopkins COVID-19 Behaviors dashboard (e.g., percentage of the unvaccinated to report perceived structural barriers holding them back)

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ASSESSING

TRUST

This model highlights fundamental trust differences across the countries studied – pointing to different leverage points, challenges and opportunities to drive vaccine uptake and build trust in the broader HCS

Kenya … OF THE HEALTH SYSTEM

Nigeria …. OF THE COVID19 RESPONSE

… OF THE HEALTH SYSTEM

…. OF THE COVID19 RESPONSE

Pakistan … OF THE HEALTH SYSTEM

TRUST IN THE PROMISE…

TRUST IN THE PROMISE…

TRUST IN THE PROMISE…

TRUST IN THE THE DELIVERY….

TRUST IN THE THE DELIVERY….

TRUST IN THE THE DELIVERY….

In Kenya, economic pressure drives natural links between the COVID-19 vaccine and a return to prosperity. But blanket mandates & harsh enforcement of infection control measures threaten to erode this trust in the promise by failing to connect the vaccination effort to what truly matters in people’s lives.

In Nigeria, extremely low institutional trust necessitates high reliance on personal networks to secure information, access, and resources. Maintenance of personal reputation is therefore paramount – and with vaccine access difficult and limited, many influencers are not willing to take the personal risk of encouraging vaccination.

…. OF THE COVID19 RESPONSE

In Pakistan, an efficient vaccine roll-out has reached many, at least in urban centres. Less attention has been paid to the promise of the vaccines, however, with negative sanctions heavily leveraged to drive motivation. This approach risks the erosion of long-term trust in the health system promise.

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ASSESSING

TRUST

With limited resources, effective trust-building requires prioritization, which requires understanding what lies behind particularly low areas of trust – and targeting these with the right tools

1

2

3

P RO R I T I Z I N G T RU S T G A P S

FOCUSING ON A QUA D R A N T

T RU S T C O M P O U N D S OV E R T I M E

Identifying and prioritizing areas where trust is low, using the trust assessment model.

Understanding the trust basis in each quadrant and working with the right tools to address this.

Allowing natural compounding mechanisms to grow trust in other areas over time.

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BUILDING

TRUST

In each quadrant of the emerging trust framework, trust is based on different expectations – and built through different approaches

TRUST IN THE PROMISE…

TRUST IN THE DELIVERY….

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

Is based on a set of expectations for what the health system – and the broader systems it connects to – should provide

Is based on a clear expectations for how COVID19 vaccinations can help communities move past the impacts of the pandemic

Trust here is built slowly, through repeated interactions which confirm or challenge these expectations

Trust here is built (and destroyed) quickly and, and relies on dialogue with the right types of advisors, as well as the right experiences

Is based on an understanding of the mechanisms underlying health delivery, e.g. how new medicines are developed or the logistics of healthcare delivery

Is based on the feeling that COVID-19 responses have been logically and reasonably applied

Trust here is built through consistent positive experiences and absence of major negative ones

Trust here is built through vaccines which align with community experience, and is heavily colored by trust in health system processes overall

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PA K I S TA N

Case study: Building trust in the promise & trust in the delivery in Pakistan Photo: A mother and her child at a vaccination centre in France Colony, Islamabad.

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THE BIG PICTURE

In Pakistan, a comparatively fast and effective vaccination effort has provided a large portion of the population with their first shot – and set authorities up for an even faster response for future pandemics

So far, a strong vaccine roll-out has managed to administer over 126 million doses

People are largely aware of the availability of the vaccine and that it is accessible to them

Key stakeholders are confident in the effectiveness of the vaccine roll-out

The vaccination effort has also allowed the government to prepare for future crises

81,8* million people (37%) have

“People prefer the vaccination van as it is more convenient, and it visits the area every few weeks. The process was very smooth, and it did not take me very long to get my dose.”

“It is very tricky. But we accepted a challenge within a challenge and we have been successful so far. We even started coproducing the CanSino vaccine.”

Improved tools for health data collection and disease surveillance are some of the outcomes of the government’s response that ensure long-term readiness

received at least one dose

52,3* million people (23%) are fully vaccinated

– Maj. Gen. Aamer Ikram, NIH Director

– Farhan, 24, Karachi

*December 6, 2021, https://covid.gov.pk/ 25

THE BIG PICTURE

Despite these efforts, COVID-19 has been a devastating chapter for many Pakistanis – particularly socioeconomically for the vulnerable groups we studied, driving disconnect with the pandemic response Profound economic suffering

Education & training disrupted

Global opportunities lost

For many in Pakistan, the COVID-19 lockdowns wreaked economic havoc – removing livelihoods overnight. Mean income fell by over 42% during the first lockdown period and hasn’t yet completely recovered.1

For many, COVID-19 has been a forced pause in educational progress, with learning and training being put on hold – often with very negative mental health effects.

Those seeking out opportunities abroad were deeply impacted by order closures and divergent vaccine acceptance regimes, fueling uncertainty & delaying personal & professional trajectories.

Aliha, 26, Lahore, has been forced to put internships on hold, and feels her dreams of an academic career slipping away

Waris, 26, Islamabad, a driver, feels stuck. He got the SinoVac vaccine, but the countries he hopes to travel to do not accept it

Shagufta’s, 55, Karachi, community is supported by individual fisherfolk, who suffered hunger during lockdown as they were not allowed to fish

As the COVID-19 becomes endemic, vulnerable groups face a long-term struggle to recover from the socio-economic effects 1. COVID-19 Pandemic's Economic Burden in Pakistan, Ali Cheema, Maha Rehman, Mahbub ul Haq Research Centre (MHRC) at LUMS

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THE BIG PICTURE

In this context, conversations about the government’s response to sustained inflation and decreased purchasing power provoked intense debates as the next electoral deadline approaches In Pakistan conversations revolve around the government’s role in inflation and worsening economic conditions as a result of the pandemic (Data collected 01/11/2021 to 09/12/2021)

For comparison When the same landscape is mapped in the other two countries, results are starkly different. In Nigeria, debate is focused on a lack of trust in official government communication

Lack of trust in official government announcements

While in Kenya, chatter is largely centered on opposition to the recently announced vaccine mandates This landscape shows social media (Twitter, Instagram, YouTube, Facebook, forums, and blogs) conversations related to the government’s COVID-19 response in Pakistan.

Darker spots indicate clusters of posts sharing a similar theme, while proximity of clusters indicates relationships in the conversations.

Public opposition to the restriction of government services for the unvaccinated

COVID-19’s role in inflation & other economic worries

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THE BIG PICTURE

To continue alleviating the pain caused by the pandemic, the vaccination effort is now at a critical stage where it needs to reach the unvaccinated, while ensuring Pakistanis come back for their second doses Women are a key demographic at risk of being left behind in the vaccine effort

People farther from the state’s reach also face greater challenges to get vaccinated

For all people with a first dose, only 38% are women. This gap is also present in second dose statistics (63% men, 37% women).

Access issues were also expressed by vulnerable respondents who struggle with digital access and who are further away from urban centers.

The idea that women have limited mobility also affects vaccination rates: “My wife is not vaccinated and it's not necessary for her yet because her mobility is restricted”

“There was a huge crowd there. I waited for so long, but the vaccinator told me I can’t get the vaccine. He told me about the Nadra system, but I didn’t understand it, so I left and never went back again”

– Hamoon, 32, Lahore

– Salim, 47, Lahore

While access is critical, motivation – trust in the outcome of COVID-19 vaccines – will also become increasingly important for the groups currently falling behind 28

THE BIG PICTURE

While an effective COVID-19 vaccine roll-out is driving trust in the delivery, without a focus on building trust in the promise, Pakistan’s vaccine drive risks losing steam and leaving the vulnerable behind

TRUST IN THE THE DELIVERY….

TRUST IN THE PROMISE…

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

A broken welfare state promise and highly privatized healthcare landscape drive distrust in the good intentions of the health system

The lack of a ‘promise’ – a motivation to get vaccinated – manifests in low second doses, and will be critical for reaching women and vulnerable groups

In a complex health landscape, people rely heavily on advisors to navigate – making credibility a key consideration

The COVID-19 vaccination journey is characterized by a lack of information, leading people to drop out at different stages and to piece together a narrative which resonates

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T H E H E A LT H S Y S T E M P R O M I S E

In Pakistan, government has made a powerful promise to increase its citizens’ welfare – but as citizens compare their experiences with this promise many feel as though the commitment has been broken … But communities continue to shoulder the responsibilities that enable their own welfare…

… Thus perpetrating a sense of neglect that deepens mistrust in healthcare systems and providers

“It was always a dream of our founding fathers to make… Pakistan an Islamic welfare state.”1

Communities bear the burden of fulfilling their welfare, often grouping together to support their most vulnerable members.

As recently as during Eid-Milad-un-Nabi celebrations, Prime Minister Imran Khan reiterated his powerful ambition to spearhead Pakistan’s transformation into a welfare state, emphasizing the importance of upholding every citizens’ rights, “regardless of their caste or creed.”1

In this context, communities not only feel left behind, but the intentions of both individual healthcare providers – and the system at large – are increasingly questioned

“These days the doctors have stopped being messiahs for the people and have turned into money minting enterprises” – Rana, 33, Lahore, a political leader in Manzoor Colony

PM Imran Khan, Eid-Milad-un-Nabi statement, PM’s official FB page, August 19, 2020 “Eid Milad-un-Nabi,” TheNews.pk, October 19, 2021 1

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T H E H E A LT H S Y S T E M P R O M I S E

Women in particular have to shoulder the responsibilities (and psychological burden) of community development – with COVID-19 presenting an opportunity to shift their perception of being left behind Women are particularly involved in alleviating the gaps left by government – and feel let down Despite efforts to self-organize to fulfil residents’ needs, communities find it difficult to alleviate the consequences of poor public services.

Water drainage is one of the basic services that residents of communities like France Colony need, with implications for their long-term health. Water-borne diseases continue to represent a concern for many residents here.

Women specifically have shown that they bear the psychological burdens of their community’s wellbeing – playing an outsize role in self-organization, and being affected more directly by poor community services.

“I want our community to prosper. We’re good and hardworking people, we just don’t have many outlets to showcase our talents.

People see us and they think we’re poor and skill-less but that’s not true.”

– Khalida, 62, Karachi

In this context, COVID-19 provides an unprecedented opportunity to exemplify the benefits of a caring state which puts citizen welfare first.

The government’s COVID-19 response is not currently perceived as the benevolent act of a welfare state – with a large burden for supporting those affected falling to communities and caretakers, and great suffering amongst vulnerable communities.

“Lockdowns were the need of the time, but it should’ve been managed better and people who needed compensation should’ve been properly assisted” – Manoj, 46, Karachi 31

T H E H E A LT H S Y S T E M P R O M I S E

Increasing trust in the healthcare system will require building confidence in the healthcare system’s commitment to welfare – of which the current vaccine drive is a manifestation

TRUST IN THE PROMISE…

… OF THE HEALTH SYSTEM

E M E RG I N G T RU S T L E V E R S : • Ensuring that the welfare promise of the national health system is understood and internalized by HCPs at the grassroots level • Communicating a narrative that clearly establishes a link between current COVID-19 efforts and the promise of the healthcare system as a whole • …

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T H E C O V I D - 1 9 VA C C I N AT I O N P R O M I S E

International messaging and actions are not currently driving much trust in the promise of the vaccination effort – highlighting the importance of local and national efforts in this area In the globalized pandemic context, international actions are noticed from afar…

… and can profoundly impact motivation to access vaccines for people well beyond national borders

The rejection of AstraZeneca in some western countries, for example, made a big impression, as have sweeping Omicron-related travel bans imposed on large swaths of Africa.

Given that COVID-19 isn’t perceived as an urgent health threat to many, and vaccination is often more tightly linked with goals like travel abroad, uncertainty around which vaccines are accepted for travel can drive hesitancy.

“Sinovac is not accepted for travel.

But what do people do about it?

They’re stuck.”

– Waris, 26 (Islamabad) is hoping to visit his cousin in Turkey soon, but isn’t sure he will be able to as he has only been vaccinated with Sinovac, which is not accepted by Turkey.

Without a reliable international ecosystem to foster trust in the promise, the pressure is on national influencers to build and safeguard trust in the promise.

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T H E C O V I D - 1 9 VA C C I N AT I O N P R O M I S E

Currently, looming threats are a major force driving people to get vaccinated – and we see people responding to the necessity to get vaccinated often as a family unit

Unrealized or inconsistently enforced threats push unvaccinated individuals to get the COVID-19 shot…

… pushing families to play an important role in understanding and negotiating perceived high-risk vaccination decisions

Threats to the unvaccinated include restricting access to services, such as blocking SIM cards, access to parts of a city or to fuel purchases, a prospect which drove Sethi, 48, a rickshaw driver from Lahore to get his first dose. Though some of these threats have been realized (e.g. school access being denied to children whose parents are unvaccinated) many have not.

Decisions to get vaccinated are fraught and require much family discussion, especially in the absence of advisors that can respond to the collective consequences of COVID. Zakariya, a 75-year-old retiree from Karachi did not get vaccinated until his hesitant wife put her fears around the vaccine aside.

In many cases, health workers bought into this narrative, warning citizens about punishments for the unvaccinated.

“My wife was worried that people who got the vaccine will die in two years, so I also did not get my dose until recently. I told her, if we die, we die together. If you don’t get the vaccine, then neither will I.”

“You should get vaccinated otherwise the government will eventually charge for it… travelling will become extremely challenging” – Lady Health Worker, Islamabad

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T H E C O V I D - 1 9 VA C C I N AT I O N P R O M I S E

In contrast to short-term coercive measures, social media conversations indicate that Pakistanis are looking for long-term solutions to the medical issues raised by the pandemic Preventative measures dominate online COVID- related conversations

Both Pakistani social media users and medical professionals are seeking out sustainable approaches to health amid the pandemic Social media listening indicates that many Pakistanis believe that taking preventive measures, such as hand-washing, social distance and healthy-eating, are more effective than vaccines in preventing infections.

Focus on preventative measures over cures

Conversations in all three countries for comparison

However, this does not mean that Pakistanis expressed more distrust in COVID-19 vaccines; distrust was lower among Pakistani social media user than those in Nigeria or Kenya. Instead, this suggests that individuals are looking for solutions embedded in a long-term approach to health, rather than cures to COVID. This was also echoed by medical professionals from the Pakistan Medical Association.

“Those who suffer the most from COVID are people with comorbidities, like diabetes – which is an issue in Pakistan. We need to focus more on prevention.”

– President of the Pakistan Medical Association, Sindh branch

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T H E C O V I D - 1 9 VA C C I N AT I O N P R O M I S E

The family context is important to drive vaccine decision-making as it is tightly linked to a generalized goal of familial improvement – with the ‘family project’ as a powerful shared aspiration Family projects can take various forms, but they can often be linked to the vaccine as a key enabler Proof of vaccination is required to travel abroad

Childhood education requires family vaccination

For Becky, the vaccine is key to get her family back to the Ukraine and her daughter to Italy for better quality of life

For Abdel Kader and his family, getting the vaccine was necessary to keep his children in school, a key component in the family project

“In the next five years we want to move abroad and settle there. My daughter will go live with her husband in Italy. No one values humanity in Pakistan; it's not like this abroad” – Becky (36, Islamabad)

“I have gotten one dose and I will get the second one in the coming week. I had to get vaccinated because my children go to government schools and there the teachers asked for proof of vaccination of the whole family.”

– Abdel Kader (48, Lahore)​

The clearer the link between vaccines and family success, the stronger the motivation, and the better women can help drive vaccine uptake Vaccination campaigns may benefit from specifically speaking to women, as key communicators and drivers of the promise to get the vaccine. They already have the passion and the position to drive action in their families. The link will provide them with the tools to better execute that passion and role in the quest for family success “Everyday I tell my family never let go of your faith in God so one day your children will do better than you did and have great success.”

– Khalida (62, Karachi) 36

T H E C O V I D - 1 9 VA C C I N AT I O N P R O M I S E

Increasing trust in the COVID-19 vaccination drive promise necessitates a more coherent response that speaks to communities’ motivations rather than threatens individuals

E M E RG I N G T RU S T L E V E R S : • Providing clear messaging about, and engaging in consistent enforcement of, potential restrictions to the unvaccinated • Linking COVID-19 vaccination to familial and community-based goals that particularly motivate women and vulnerable communities

TRUST IN THE PROMISE

OF THE COVID-19 RESPONSE

• …

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H E A LT H C A R E D E L I V E R Y

The healthcare landscape in Pakistan is a complex patchwork of public and private healthcare providers, the latter serving 70% of the population, with varying levels of expertise, training and recognition PUBLIC

PRIVATE

LHWs

Doctors & nurses

Quack doctors

Hakeems

Dae

Government employees, who raise health awareness at the community level

Healthcare professionals with governmentsanctioned. Credentials, working in the public and private sphere

Healthcare professionals with “experiential” credentials, i.e., lab technicians, doctor’s son, etc.)

Traditional healers, herbalists, who provide not only health advice but also “life guidance”

Doula, birth attendant, who provides health advice for women, specifically pregnant ones

“My duties include… visiting 7 to 8 households everyday [and] to raise awareness about family planning… but the program has gotten involved in many other things”

“I go to the same doctor every time. This doctor sits at Holy Family Hospital, which is a popular public hospital in Pindi.

He also has a private clinic at Al Shafi Hospital”

“I have trained under a very experienced doctor myself… On top of everything I have 6 years worth of experience of working as a pharmacist.”

“I started hikmat by reading some amazing books about medicine and diseases. Now I am an expert in my field but there is a lot more to do.”

Naheed, 37, Lahore, goes to a dae for any issues relating to her reproductive health. The dae provides herbal cures and assists with pregnancies.

– Naz, 46, Islamabad, a LHW

– Jamal, 25, Rawalpindi

– Abdul Ghafoor, 28, Lahore, a neighborhood quack doctor and lab tech

– Abdul Hakeem, 85, Lahore, a traditional healer with 30+ years of experience

Individuals need help navigating this diverse landscape, particularly during the pandemic, which introduced even more uncertainty and complexity 38

H E A LT H C A R E D E L I V E R Y

As people are pulled in different directions in the healthcare system, they build their own ways of navigating – with a heavy reliance on different types of advisors TRUST IN PUBLIC

TRUST IN PRIVATE

LHWs

Doctors & nurses

Quack doctors

“We also get awareness about health issues from lady health workers. I usually consult lady health workers when I get sick” – Hania, 32, Islamabad

“I go to Jamal Noor hospital…

I’m very satisfied with my doctor, he’s renowned.

Whatever course of action he prescribes, I follow regularly.”

– Habib, 65, Karachi

“In our area, people rely on quacks and homeopathic doctors for treatment because they don't suggest tests, rather provide medication on a single visit” – Tariq, 27, Lahore

Hakeems “For health issues like vomiting or influenza, we go to hakeem for herbal medicines” – Kareem, 62, Lahore

Dae “When I got pregnant with my 7th child, my pregnancy got complications… I went to dae, who lived in Qasoor, for a check up. Dae suggested to me a mixture of some herbs to take orally.” – Naheed, 37, Lahore

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H E A LT H C A R E D E L I V E R Y

When it comes to advice, the credibility of the advisor or source is of critical importance – and sources of credibility are differentiated by type of trust, making some better suited to building delivery trust Credibility here is derived from:

Advice building trust in the promise comes from sources with expertise in the social world

• • • •

Proximity to truth or special insight (e.g. religious leaders) Societal success (e.g. successful business leaders, some politicians) Understanding of particular circumstances & context (e.g. long-term connections) Perceived positive intentions (e.g. family)

Credibility here is derived from:

Advice driving trust in the delivery comes from sources with expertise in the world of health

• • • •

Family legacy and experience (e.g. traditional healers, CHWs) Proximity and control over resources in the health care system (e.g. access to experts) Recognized accreditation (e.g. degrees, public recognition) Perceived need to retain community trust (e.g. some politicians, community leaders)

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Case study: As experts in the social world – and therefore credible advisors within the promise but not the process – religious leaders have struggled to engage with the highly healthand process-related COVID-19 SOPs

As experts in the social world, religious leaders are well-positioned to provide advice on a broad range of important areas In all three countries studied, religion occupies a central role in public life, and religious leaders generally poll as highly trusted (e.g. in Kenya and Nigeria, survey respondents rank religious leaders as the most trusted institutional leaders1,2).

At a community level, religious leaders are tightly integrated with their congregants, and play a key role in social cohesion.

But they rarely become involved in the practicalities of health decisions – dealing instead with the implications of health, or stepping in a last resort Religious leaders across faiths guide people through key life decisions – from marriage to career.

When it comes to health, they tend to step in to help deal with sideeffects of health, e.g. the financial implications of illness, or when no other treatment options remain.

During the pandemic, many have been asked to instruct their congregants on practical COVID19 SOPs – and many received backlash “The police arrested me for not maintaining social distance while leading the prayer. I told the police the people have their own opinions. I can't make them do anything against their will” - Saad, Imam in Lahore

Leveraging religious leaders’ trusted role in communities better means getting them on board with the promise – enlisting their help to build motivation amongst those who trust their social guidance Religious leaders were most engaged in the COVID-19 response when they personally bought into and promoted collective interests over individual preference behind the vaccines. They are wellpositioned to build motivation in an area where they already enjoy high credibility.

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H E A LT H C A R E D E L I V E R Y

Increasing trust in the healthcare delivery necessitates to take a fresh perspective on identifying influencers and the type of support they are best able to provide

TRUST IN THE DELIVERY…

… OF THE HEALTH SYSTEM

E M E RG I N G T RU S T L E V E R S : • Ensuring that advisors who already enjoy high credibility within delivery-related trust are well-equipped to guide communities through the pandemic response – while those credible in the promise are also provided with the right tools • …

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T H E C O V I D - 1 9 VA C C I N AT I O N D E L I V E RY

The COVID-19 vaccine journey in Pakistan is characterized by relatively easy access to vaccine sites (for the urban), but with challenges to getting information, answers to concerns, and clarity about next steps Decidingto toget get Deciding the vaccine the vaccine

Finding a Finding a vaccine site vaccine site

An individual decision with family consequences

From small community sites to vaccination vans

As part of the decision to get the vaccine, individuals consider the reasons and consequences for the family.

Finding a site is primarily based on geographic proximity to individuals’ locations.

For example, for many, like Abdel Khader, getting the vaccine is a necessary step for their children to attend school.

For Becky and her family, this means being able to live abroad in Ukraine.

Registering for Getting the vaccine registered

Getting the the Getting vaccine vaccine

Obtaining the 2nd dose

A key pain point and challenge for many

Smooth for many, but hard for those with questions

Several barriers keep many from reaching this step

Some people are able to get the vaccine on the first try at their local clinic…

Getting for a second dose involves getting an SMS that it is time to visit a facility.

In certain areas, people also have the option of accessing vaccination vans.

Registering for the vaccine can be difficult, especially for those that struggle with smartphones.

Additionally, during peak hours, registering for the vaccine onsite can take a long time.

Below is a small community site in a community leader’s home in Dhok Hassu, Rawalpindi.

Like for Salim below, an unsuccessful registration step can become an exit point out of the journey.

…while others, especially those with questions like how the vaccine interacts with comorbidities, might be referred to a larger facility.

It also involves knowing if the vaccine taken requires a second dose, and finding that same vaccine available

Below, a young man gets the vaccine in Dhok Hassu.

For some, like Farhan below, it also means waiting for the vaccination van to return.

Life postLife postvaccines vaccines Share stories and living with uncertainties After getting the vaccine, people inevitable share their experience and influence others.

Additionally, a variety of uncertainties still remain. For example, Aliha below questions the efficacy of the vaccines, after having gotten COVID-19 despite being vaccinated.

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T H E C O V I D - 1 9 VA C C I N AT I O N D E L I V E RY

Throughout this vaccination journey, people struggle to find information to key questions like type of vaccine received, whether a second dose is needed, and how vaccines interact with co-morbidities

Habib, a 65-year-old man from Kharader, Karachi

Kalsoom, a 62-year-old woman from France Colony, Islamabad

Vaccination staff and a patient in France Colony, Islamabad

Kausar, 43, Lady Health Worker from Karachi

People have important knowledge gaps in their journey…

…Yet, answers are not always readily available

Which vaccine did I get, and do I need a second dose?

Should I take the vaccine if I have another condition?

Vaccine site staff defer answers to larger facilities

Lady Health Workers feel unequipped and uniformed

Habib was not aware that he got a single-dose vaccine instead of a twodose vaccine, until he went to a vaccine site

Kalsoom is worried about her health condition (joint disease) and how the vaccine might affect it

This is particularly in the case when people have co-morbidities and underlying conditions and ask if the vaccines will affect them.

LHWs are expected to advise on COVID & vaccines. When they can’t, their role is undermined and people are left with further uncertainty.

“Our COVID trainings don’t cover what the virus or vaccine are. We lose people’s confidence when we can’t give them detailed answers” – Kausar, 43, Karachi

“When I went a second time to the vaccine site, they tell me I don’t need a second dose for PakVac” – Habib, 65, Karachi

“When I went a second time to the vaccine site, they tell me I don’t need a second dose for PakVac” – Kalsoom, 62, Islamabad

This affects people in the “getting the vaccine stage” as for some, it means they need to travel to a larger facility to get answers.

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T H E C O V I D - 1 9 VA C C I N AT I O N D E L I V E RY

In the absence of well-equipped advisors and clear answers, people turn towards other sources of information – such as television or social media – that are often considered to be unreliable

Yomez (74, Islamabad) in his home in France Colony

A family gathers to watch TV in Emporium Slums, Lahore

Television

Aliha (26, Lahore), an avid social media user

Kareem (62, Lahore), in his neighborhood in Emporium Slums

Social media

Local TV channels are a common and accessible source of information, but not always a trustworthy one

Local TV is the main lens through which people perceive international news, including COVID-19

Social media is also regularly used as a source of information, though it is not to be blindly trusted either

Even for those who do not use social media on their own, they still engage “second-hand” media consumption

76.2%1 of Pakistani adults watch TV at least weekly.

“I watch the news mostly. 92 News is a channel that’s popular these But it's hard to act on the news we get from television.

I think all news is fraud, I don’t pay much heed to what they say on the news” – Yomez, 74, Islamabad)

National channels like Geo News, Dunya News, Aaj TV, ARY news and others dominate the media landscape in Pakistan, while international news agencies are more rarely consumed – Media landscapes, Pakistan, Television

“I use social media to get any information.

Sometimes social media spreads rumors, but still I get news about anything from social media. Twitter is the most reliable source for me” – Aliha, 26, Karachi

“It needs electricity to watch TV and we don’t have it. Our children have mobile phones, and they use Facebook. They sometimes give us information on daily life” – Kareem, 62, Lahore

1

Gallup BBB Report (2014) on Contemporary Media use in Pakistan

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T H E C O V I D - 1 9 VA C C I N AT I O N D E L I V E RY

In this confusing and uncertain information landscape, people construct their own realities about COVID-19 and the vaccines, often filling real unanswered concerns with myth and misinformation Theories about the United States cover gap abouts about the origins of COVID-19

Rumors about effects on male sexual health fill gaps about the consequences of the vaccine

Women hesitate about the vaccine might harm their fertility

Short-term side effects, unexplained, are understood by many as “allergies”

“People in my community say that COVID is an American curse and I think they are right. Infidels have always been our enemy and they want Muslims to suffer.

My baji (whose house she works at) is educated and she also shared the same belief, which means it's true”

“…Nor I am sure what effects this vaccine will bring. There are a lot of rumors regarding it like people will die or It will affect the sexual performance or male potency. I am confused regarding the validity of these rumors as there is no way to corroborate it”

“Women here have two common perceptions regarding covid vaccines which they shared with me in my salon, one is the fear of death after two years of taking vaccines, and the second is the fear of infertility that is believed to be caused by covid vaccines”

“There are a lot of myths circulating about the COVID vaccines. People have made out natural allergic reactions to the vaccine that everyone will go through. I tell people the allergic reactions can be managed really easily through an injection”

– Naheed, 37, Lahore, a domestic worker from Emporium Slums

– Tariq, 27, Lahore, a hotel manager from Beer Pind

– Hania, 37, Islamabad, a beautician from France Colony

– Abdul Ghafoor, 28, Lahore, a “quack doctor” from Manzoor Colony 46

T H E C O V I D - 1 9 VA C C I N AT I O N D E L I V E RY

Equipping advisors and vaccinators with answers to common issues like the vaccine types, side effects, comorbidities, and second doses could significantly improve the current vaccination journey Current gaps represent a clear entry point for improving the vaccination journey and drive uptake Ease Registration

Discuss sideeffects

State vaccine availability

Equip advisors

Greater detail about the registration process can help prevent long wait times and people from existing the journey

Greater detail about the registration process can help prevent long wait times and people from existing the journey

Lists of vaccine types available in a site can let people quickly determine if they need to travel elsewhere for their second dose

Training & equipping LHWs & vaccinators with information can empower them to make the vaccine more human and less uncertain

Address the delivery process while impacting perceptions Taking action to leverage these opportunities has the potential to improve the process of getting the COVID-19 vaccine and to reinforce perceptions that welfare is at the center of the health system’s mission.

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T H E C O V I D - 1 9 VA C C I N AT I O N D E L I V E RY

Increasing trust in the delivery of the COVID-19 vaccination will require answering individuals’ most pressing questions about the vaccines and the delivery to obtain their – multiple – jabs OF THE COVID-19 RESPONSE

• Establishing more touchpoints throughout the vaccine journey that help individuals engage in honest conversations about their doubts, fears or concerns with advisors • Ensuring the delivery can be adapted to individuals with varying levels of technological literacy and embeddedness in government systems across vaccine sites

TRUST IN THE DELIVERY

E M E RG I N G T RU S T L E V E R S :

• …

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CONCLUSION

Leverage points in each of the trust areas indicate that the opportunity for trust building both promise and delivery trust in Pakistan is high – across the health system and the COVID-19 response

TRUST IN THE THE DELIVERY….

TRUST IN THE PROMISE…

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

Creating a greater link between the current vaccination campaign and the ambition to make Pakistan a welfare state

Establishing a clearer link between vaccines and family success, while specifically targeting women as the keepers of community goals

Identifying and targeting specific types of influencers for specific types of informational campaigns

Aligning the vaccination delivery with individual needs for dialogue surrounding vaccines, while easing registration requirements for the most vulnerable

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EMERGING TRUST FRAMEWORK

Next steps: this model represents an emerging theory for how trust impacts might be determined. To develop it further, practical application and measurement will be required

1. Further definition of KPIs & synthesis of leverage points

Continued analysis, including stakeholder and expert consultation, to strengthen and more tightlylink the trust framework with existing KPIs. In addition, examining the specific trust building levers which could be linked to each of these KPIs

2. Development of pilot scenarios to test and strengthen framework

Working with in-country partners to develop health interventions which might be used to measure and validate the trust framework, e.g. vaccinator training initiatives which could be used to test how improvement in trust in the delivery might be fostered

3. Iteration and strengthening of the framework based on pilot tests

The trust framework will be collaboratively developed further based on learnings from the pilots

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Appendix

Additional context & methods notes

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APPENDIX

Context: ‘Trust’ as a concept has been well investigated, both within and outside of BMGF – for example through the identification of concrete barriers and drivers of trust A key finding throughout much of this work is that trust is a key ingredient of demand vaccinations.

Barriers and drivers of childhood vaccination have been identified

An interdisciplinary corpus focuses on the social context of intervention uptake

• BMGF has conducted extensive research on drivers and barriers to vaccine uptake • E.g. a pre-Covid Ipsos Global Health study provides an overview of the factors that hinder infant vaccination through quantitative, survey and interview data

A growing body of literature in fields ranging from political science to epidemiology investigates the types of social ties and structures that affect the acceptance of a variety of health interventions, including largescale vaccination campaigns (e.g., polio)

“Context, prior experience, and citizen trust are crucial factors that determine engagement and uptake [of vaccines].”

Source: Sameen M. Ali & Samia W. Altaf, “Citizen trust, administrative capacity and administrative burden in Pakistan’s immunization program,” JBPA, Vol 4(1), 2021

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APPENDIX

Project Goals: Through the Trust Framework, trust is explored as a mechanism for driving health systems change through community engagement – with three major goals Three major goals for this work STRATEGIC VISION

STAKEHOLDER ENGAGEMENT

PRACTICAL TOOLSET

The framework will provide a structure for bringing together and making sense of disparate existing data streams

Framework development – and subsequent implementation workshops – will provide a focal point for knowledgesharing

Practical tools for working with trust (and so increasing vaccine uptake) will be collaboratively developed based on the framework

This might include e.g. round table talks (such as the UNGA side event on community understanding and trust), workshops, or collaborative publications.

These might include e.g. trust KPIs or measurement guidelines, training modules, etc., refined through possible pilot initiatives with partners.

The Trust Framework does not replace existing work – but provides a lens and guidance for how existing data might fit together to provide useful guidance.

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