How can the health sector prioritise reducing health disparities, and promote equity? As a group of public health researchers and practitioners, we recommend for consideration the following strategies and responsive action:
#1 Utilise equity as a priority for vaccine distribution: After vaccination of those that belong to the Tier 1 group (the elderly, immunocompromised, and healthcare workers), prioritise equity for vaccine distribution should to those who comprise Tier 2 by identifying socially and economically underserved communities: Nepal is replete with available data, be it routine health information systems like the HMIS, the Nepal Demographic Health Surveys, the Survey of the Nepali People, Nepal Living Standards Surveys, and other databases.
These databases can be utilised to identify communities and geographical clusters of economically disadvantaged, and socially excluded, communities. Indices of economic and social disadvantage such as the Multidimensional Poverty Index (MPI) can be used to indicate regional targeting and directing of Covid-19 vaccines.
Additional professional groups that clearly need to be prioritised include teachers, transportation, and custodial staff. The ultimate goal will be not to sort individuals at the point of vaccination.
Instead, target groups that geographically cluster to get as close to herd immunity as is possible by targeting those among the most vulnerable in the ‘herd’ to economic and health disparities.
#2 Broaden and tailor behaviour change communication on Covid-19 vaccinations: Conduct clear and cohesive mass vaccination campaigns that include consistent messaging on the Covid-19 vaccines available and their efficacy and safety. With 139 mobile telephone subscriptions per 100 people, appointment management through text messages to avoid overcrowded lines should be considered.
Further, continue the mass communication push through trusted social media, local tv channels, and radio in languages beyond Nepali or English and include Maithili, Nepal Bhasa, Bhojpuri, Awadhi, Tharu, Tamang, and more. In addition, local religious and community leaders should be engaged to spread these messages among their communities.
#3 Facilitate equitable access to the vaccine: Leverage trusted members of prioritised communities such as community leaders, female community health volunteers, and others, our suggestion is to set up vaccination drives as close as possible to these communities to overcome barriers of physical access and to sensitise communities to the intervention.
There have been reports of employees being penalised or prevented from absenting themselves from work to get vaccinated in urban centers. Such barriers and penalties must be done away with, and no citizen should fear losing their jobs if they prioritise getting vaccinated. Similarly, those misusing power to strong-arm their way into vaccine access should be penalised.
Further, youth should be mindful of why their ranked order on the list of those prioritised and at this time are required to uphold, along with everyone else, a strong sense of public health duty and the common good.
#4 Build trust: While vaccine hesitancy was high during the first wave, this has shifted during this second wave. “Initially, the older people were afraid to get vaccinated and needed much encouragement. But now people are eagerly waiting for their turn to get the vaccine, according to Rekha Chaudhari, a Female Community Health Volunteer in Sarlahi District.
However, confidence in public institutions is not equal across the population. And, in some communities, trust is low given patterns of being politically, economically, and socially disenfranchised. Hence, it is vital to clearly communicate the importance and benefits of the Covid-19 vaccines and increase easy access to the vaccine for vaccine-hesitant and the most vulnerable groups.
Locating vaccine administration campaigns near trusted community spaces in the community, including tea shops, community centers, and places of worship, is a clear step to building trust.
#5 Leverage science: Data and its use cannot be underscored enough for evidence-based action against Covid-19. As noted above, the use of available population data and routine monitoring data is imperative to guide intervention.
Additionally, given the likelihood that a substantial proportion of the population will probably be administered a combination of vaccine (say Covishield AstraZeneca to begin with and Sinopharm VeroCell as a second dose) due to the staggered and varied release of vaccines to Nepal, there is the opportunity to plan and implement studies that examine the effects of such mixing of vaccines especially amongst high-risk groups on related health outcomes.
#6 Clear and justly enforced reopening guidelines: Clear and consistent messaging on the phased, cautious reopening of the country via multiple communication channels is essential. The government’s implementation of a responsible phased reopening approach that balances economic slowdowns, people’s livelihoods with health is imperative.
The importance of undertaking these steps with a strong sense of social justice must be emphasised: protecting vulnerable populations, addressing inequities between ethnic, social, and regional groups and those entrenched in unfair patterns of power and advantage.
Advancing equitable access to Covid-19 vaccines in Nepal, once adequate vaccine procurement occurs, is a clear opportunity for addressing existing health inequities in Nepal that have been further deepened by what indeed has been a global pandemic with a discriminating path.
Nepal-Johns Hopkins University COVID-19 Vaccine Advocacy Group is made up of:
Swetha Manohar, Johns Hopkins University (JHU)
Binita Adhikari, JHU and Health Foundation Nepal
Tsering Pema Lama, JHU
Bijay Acharya, America Nepal Medical Foundation, Massachusetts General Hospital and Harvard Medical School
Smriti Mathema, Department of Paediatrics, Kathmandu University, Nepal Paediatric Society
Angela KC, JHU, Acumen
Dinesh Neupane, JHU
Santosh Dhakal, JHU