Developing a fit-for-purpose Covid-19 vaccine programme in Papua New Guinea: A conversation with Mr Api Kassman

Vaccine hesitancy has been a particular challenge for governments and health teams around the world as COVID-19 vaccines have been rolled out. In Papua New Guinea, a country still seeking to embed a system of routine childhood vaccinations, the rollout presented a challenge for the health workforce.

Our guest this week is Mr Api Kassman, Executive Director of the National Vaccine Task Force in Papua New Guinea. We discuss his involvement in the COVID-19 vaccine rollout in PNG and how the country’s first adult targeted vaccine program was rolled out. Mr Kassman speaks about the need for a shift in strategy to include fit-for-purpose, culturally appropriate interventions.

We encourage you to join the conversation at @CentreHealthSec.

Transcript

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The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.

Dr Stephanie Williams 00:31

Hello, and welcome to Season Three of Contain This. I'm Stephanie Williams, Australia's Ambassador for Regional Health Security. I'd like to start by acknowledging the Traditional Owners and Custodians of Country throughout Australia and the Indo-Pacific region. We recognise the continuing connection to land, waters and community, and pay our respects to Elders past, present, and emerging. In today's episode, I speak to Mr. Api Kassman, the Executive Director of the National Vaccine Task Force in Papua New Guinea. In his current role, he leads on vaccine supply, access, and uptake with a particular focus on the COVID vaccine deployment programme. Mr. Kassman describes the complexities of what was the first adult targeted vaccine programme in PNG. Complexities from initial vaccine hesitancy to the importance of equipping local healthcare workers with information and support those healthcare workers who are at the coalface of the rollout. Mr. Kassman articulates the importance of creating fit-for-purpose training of Papua New Guineans, healthcare workers, and culturally appropriate interventions in an already overstretched healthcare system. We hope you enjoy the conversation. 

Dr Stephanie Williams 01:47

Api, thanks so much for joining me today. I wonder if you could just start by telling us a bit about yourself and what you did before taking on the role of Executive Director for the Vaccine Task Force, over to you.

Mr Api Kassman 01:57

Thank you very much Stephanie. And it's fantastic to be a part of your podcast for today. You know, when I was first headhunted to join the team, from the minister's office, I, there was supposed to be a ministerial committee for the COVID-19 response generally. And obviously, so this is high level approved that, you know, National Executive Council, where, you know, five key ministers were put together to really drive this COVID response at that level. So that was that was the thinking. And I was going to be a key part of that in the communications area, but working really closely with the Minister for Health, who chaired that ministerial committee. When we were in the genesis of of this steering committee, we, we basically had the first you know, our first infection COVID infection, and we shifted quickly into an SOE sort of format, and we came underneath a Controller of a State of Emergency. So the thinking shifted from a high level ministerial committee towards functioning under a State of Emergency and through a State of Emergency. The Prime Minister heads that as he would have in the in the ministerial committee. And we, we basically brought all the bureaucracy and the one, one response element, which was the National Operations Centre at the time. And I was part of this whole NOC process with the minister involved. So we basically moved, we were moving on the run, and it's really synonymous with what's happened in COVID. We were learning daily about what we needed to do. So, you know, we're talking about March 2019. And that's the first infection in Papua New Guinea. And this was obviously, pre any sort of vaccination that was available to the people. Fast forward to where I am now, we've, you know, we've introduced the vaccine. And the minister said that, you know, we can't be expecting our normal routine immunisation to take on, you know, the intricacies of COVID vaccination, where we're already, you know, having challenges in that routine immunisation space. He wanted a group that was specifically targeting COVID-19 vaccination. And when we first came into office team, we we were sitting at, you know, we were struggling to get 2,000 people vaccinated at that time, and our numbers were just sitting there and so there needed to be an intervention. And, and so I sort of went from the steering committee to the to the, sorry the Ministerial Committee to the National Operations Centre, and then I was pushed into the vaccination team. So I've been part of that total response. You know, basically since day one of the, the the you know, the high level operation. But, you know, suffice to say in the department, the the the response had had kicked off way before, you know, this format. So that's I hope I answered your question. And that's how I've ended up in this role as Executive Director of the Vaccine Task Force.

Dr Stephanie Williams 05:17

That's really clear, and especially to outline your involvement in that since the very early days in March 2020 of the COVID infections in PNG. So, when you became the Executive Director of the National Vaccine Task Force, and you just said that the, there was a need to separate the planning and organisation from routine immunisation. How did you go about organising yourselves? And what were the kind of first few steps that you had to take in delivering against the objective, which was presumably to maximise vaccine coverage in PNG with COVID vaccines?

Mr Api Kassman 05:56

Yeah, yeah, that's, that's a really good and key question. The reasons why, I think was explained earlier. But the in terms of objectives, you know, certainly early on in the, in the piece, we were, our Terms of Reference were around, you know, basically jumping in and making sure that there's a, you know, we drive demand generation, there's an uptake on vaccination, and, and ensuring that the vaccination is obviously credible around the country, where there is a demand it's our responsibility to ensure that we meet the demand with sufficient vaccine supply, ensuring that, you know, whatever culture and requirements a snapshot and whatever the the culture and requirements were doing a quick rapid assessment on where we were, and our ability to, and obviously, our readiness to carry out this vaccine deployment programme. So basically, the A Bs and Cs of a normal routine programme. But, you know, when we came into play, what we were staring down the barrel of was already fast declining, routine immunisation levels, and they continue to decline. And this was pre COVID. So we couldn't use COVID as the reason why, you know, there was this decline, but there was this need, that everything needs to be coordinated through the National Control Centre, where there already were clusters and hubs set up for separate, you know, logistics, separate surveillance separate, you know, infection prevention control, so all the everything that housed the COVID response was in the control centre, and, and the mandate shouldn't be further COVID vaccination set with the State of Emergency or the National Control Centre at the time. So this was the genesis of COVID, fitting into the National Control Centre and, and it involved more more of the government players than your not your normal routine programme was. And I guess the complexity around this was that this was the first truly adult targeted vaccination programme, where everything that was being done at the department at that time, was based on children's vaccination. So obviously, the big players your WHOs, your UNICEFs are still involved, but it was mainly getting parents to carry their children in and get vaccinations, which are up to you know, you're talking about up to two years of age. And, and this was certainly a different kettle of fish, where we're targeting adults were targeting, you know, in incoming and outgoing domestic and international travelers, we were involved in, you know, monitoring what's happening across the wharves and so, so basically, how comprehensive this was, as needed to be part of the total response, understanding where the surges were, where the surges were coming from, and all of that was housed at the National Control Centre. So it made sense to, at the time to have the vaccine programme, sit at the control centre, and obviously, working hand-in-hand with the department who provided in the cold chain, who provided the expertise and the technical advice. So, you know, there's still that, you know, that that need for that strong connection with the department. But, but having a lens of everything else that was happening around COVID, and where we needed to target targeted vaccination campaigns, this had to sit here at the control centre. So that was the ideology. Obviously, when we jumped in and found out that the reasons were so vast as to why the COVID vaccination rates were not where they used to be, or where we wanted them to be. It was our ability to pause and reflect on you know, what is our opportunity? Are we here to play the long game or do we need are we looking at things the wrong way? So I guess you liked the general response, we were prepared for a sprint, that was actually a marathon. So, and I think, you know, in terms of the vaccination programme, we adopted a bit of that ideology as well, because what we noticed is that there was such a disconnect between, you know, what we knew in the control centre, and what was actually realised that, you know, if I can call it ground zero. So the shift in thinking came away from being rapidly rapidly focusing on on the incline of numbers and getting people through the door to be vaccinated, to how do we ensure that this is part of a system that we know is going to take time just to be communicated and just to be trained, so that, you know, when when, the person at the coalface, which is the healthcare worker, to ensure that they actually have all the information at that point, to be able to, you know, administer successfully, to, you know, our rural population. So, we shifted really from being something that's ad hoc that's based just on numbers to actually trying to identify the real issues. And and, you know, some provide some interventions that were fit-for-purpose and culturally appropriate.

Dr Stephanie Williams 11:24

There's so many things to follow up in that answer Api, because, you know, you've reflected on the time that was needed to do it in a way that suited the context in PNG. And that's a very, varied context across the country. Yet we were in a kind of global race against time on the COVID vaccine camp campaign globally. Could you talk a bit more about the disconnect, you mentioned, particularly with respect to healthcare workers, and some of the strategies that you have observed or implemented along the way that has improved healthcare worker update uptake, which I think is quite impressive now in PNG, from a low base. How did you tackle the questions and issues amongst healthcare workers in particular?

Mr Api Kassman 12:18

You know, it would have been easy for us to assume, and I must say, admittedly, coming into this response, that the healthcare workers, were were just automatically going to be our best advocates, because this is, this is what they do, this is the day-to-day role. And it should be just as easy as giving them the vaccines and allowing them to go out there and, you know, ensure that they can administer, you know, what we fail to realise is that, you know, these healthcare workers are people, and they are people who, who require levels of information, because they take on that responsibility of being the conduit between us and obviously, the general public. And in you know, it was that perception that everything was going to be hunky dory, if you so to speak, just give just provide them. So it was, it was just going to be a logistical challenge. But we we quickly found out that wasn't the case and and the hesitance and the apathy that came, firstly, with the vaccination was from our healthcare workers, and all our surveys will will, will speak to the point that the healthcare workers continue to be the most trusted source of information in our communities. So when the when the people at the coalface don't believe that the vaccination is appropriate, or they don't know enough about the vaccine, or they have their own questions that need to be answered first. We said let's go back to the basics. And let's let's build this programme. So one of the most important interventions for us was creating a fit-for-purpose training of the healthcare workers, where they would feel like all of their questions are being answered. They have never felt this level of hesitance in the normal day-to-day rollout of vaccination programmes. And this was because they was all of a sudden being asked questions about which factory is coming from? Is this the one that's working in this country and not working in this country? Is this the one that's had adverse effects in this country? Is this the one that's had is this the vaccine that's had, you know, all these different challenges around the world? They've never had to deal with those sorts of questions and I’ve actually been witness to some of the questions coming from the general public. And it's because, you know, you introduced that to introduce social media and you start to introduce people's access and hunger for information. We've never had that we've we've always rested on the laurels that, you know, our people will come forward because you know, they trust us or because there's no other information at the coalface, but the information that we bring. Well COVID suddenly presented a new set of challenges, you know, and, and we had to go back to basics and focus on our healthcare workers. Now, a lot of people will say that, hey, that's not the role of a task force, you're just supposed to come in, at a short term turnaround, some amazing results and walk away, you know, but our mandate was really not just to get the update, but to understand why there was no uptake or why the demand wasn't there. You know, through different strategies, we will now sitting at around, you know, half a million doses administered, but that's nowhere close to where we need to be. But, but we're obviously, we got some small victories to talk about. And, you know, when people talk about the COVID-19 vaccine experience, you know, you can always focus on jump on, you know, what's gone wrong, and there are plenty of lessons to be learned, not just in Papua New Guinea, but around the world, but I think I'm especially pleased with the key development partners have come together to to coordinate and collaborate with the government of PNG. You know, this is often a normal challenge, when we're rolling out programmes, because there is a culture of, you know, different partners working in isolation. And, and obviously, you know, if the, the only thing that this will, this will basically, basically, achieve is a confused population. So, you know, the, there were many partners with a clear strategy or a strong government leadership coordination, and this is what the task was, you know, basically looked at developing a clear strategy, that and, and providing the government leadership as it needed. So, you know, I'm really pleased to say that, you know, we are now working in coordinating, there's a model, and there's obviously areas of of, of improving the development cooperation, we're also reaching out to all partners engaged in vaccination with, with sort of regular communication, virtual learning, and engagement sessions and targeted workshops. So so so to ensure that we're working in a coordinated effort, and informed way, you really under one key strategy, which we call the blueprint, and we're seeing that slowly, you know, get the results that we needed the PHAs, I guess, before the response as well, PHAs, were, were in some provinces, or new concept. And so for those who don't know, a PHA is our Provincial Health Authorities. So we've, there's a model that sits there and talks about a framework that decentralises health in Papua New Guinea, but, you know, actually seeing it, seeing it in action is a totally different thing, because it sits such as still a strong reliance on what happens at Waigani. And, and driving, you know, who's responsible for what, who really are the custodians of health? So there's some bigger issues, and which, which created a challenge for people and the vaccine rollout. Who's running the programme and who isn't? You know, and, and I guess from the task force very early on in the piece, we established, the custodians of health of the public Provincial Health Authorities, because they've got the access to the people, and we basically need to feed them with all the information so we can work down through their channels and use existing government systems to roll this out. Because the existing government systems is what our people recognize and what our people trust. And, you know, trying to create a parallel system or trying to create a new way of thinking, while we're introducing a new vaccine was always going to be, you know, you know, was always going to be received with, you know, challenge.

Dr Stephanie Williams 18:57

You talked about celebrating successes, and, you know, in terms of reaching important milestones, and what is the coverage in healthcare workers currently, is it around 70 per cent in PNG?

Mr Api Kassman 19:10

Yeah we’re looking, you know, upwards of that the last report that I looked at, you know, we've got a, you know, a 15,000, strong health, health worker, you know, sort of the numbers that we're looking at. And, you know, our numbers were looking upwards of 70 per cent already, you know, but we, there's so much we could do more, and when you say healthcare workers, you know, we're talking about everybody that works in that health space. So, you know, we need to take a deeper dive into the actual healthcare workers not just talking about support and ancillary stuff, but you know, we're, we're, we're satisfied that we're, we're doing, you know, we've started the process, and we just need to soldier on and be consistent with what we're doing in that space and obviously, refreshing that learning and having a system where we refresh that learning, so that so that we can ensure that they have all the information that they require, you know. To say that we, you know, the game is in front of us and we won, it I think that's naive. We've, we still got a long way to go.

Dr Stephanie Williams 20:13

So what do you think is a practical future for how we continue with COVID vaccination but as you said before COVID, routine immunisation was slowing down in PNG. And, you know, we it's too easy for us to say, you know, on a podcast that oh, we should just integrate COVID vaccine with routine immunisation, but our systems are set up very differently and the rationale behind the vaccines are very different. And speaking as candidly as you feel comfortable in doing, I'd be interested in what you think is the best vaccine strategy or strategies in short term for public health outcomes in PNG.

Mr Api Kassman 21:04

If I'm speaking candidly, you know, one of the biggest challenges for us is working in a, in a weak health system. It's underfunded, it's overstretched. And many of the people working on COVID-19 vaccination at the national and sub-national levels are the same people who are responsible for routine immunisation and other health services. This has been a major problem because we can't do everything well, in a weak system. There's an opportunity costs with, you know, with each effort, as such, the task forces work to provide our partners with additional resources and support, coordinating, supporting, supplementing when necessary, but there's certainly a lot a long way to go. We're concerned about obviously, the very low rates of routine immunisation in PNG and the fact you know, misunderstandings of COVID-19 vaccination as well as strength, stretched, sorry, health systems, due to COVID-19, and how that contributed to even lower rates for our children. So, you know, really understanding the risks of integrating or rushing to integrate, which is, which is the easiest thing to do for us to say, let's, let's make sure that we're not running parallel systems, let's make sure that, you know, we can normalise COVID vaccinations as quickly as possible. But you know, the unintended consequences that can come with that, we really need to understand what they can be. And obviously, a, you know, some some, every Provincial Health Authority, you know, there's no one size fits all that we were dealing with, with different thinking people, we're dealing with different, you know, challenges in terms of geography and getting vaccination out to people. So it's really horses for courses in the different provinces in PNG, you know, and I think the only way that we can, we can really achieve the results that we want, is through partnership and through working with, you know, the people who are already on the ground and who are trusted, you know, there are people not in the COVID space, but for example, working in Malaria, working TB, working HIV, and we've basically got to find a way that we can piggyback off the people there who are reaching those, you know, the people who are who are most disadvantaged in terms of geography and access to health services, we've got to find a way that we can pull all these partners together and say, ‘hey, we need to take COVID out together’, because there's some fantastic success stories and in TB and HIV, and, and we need to really piggyback on that with COVID and, and safe to say that, in COVID, we've had some success that, you know, the other sort of public health challenges haven't received, and they need to jump on the back of COVID. You know, the fantastic, you know, reach that we've had through the private sector, you know, especially the mining and petroleum sector where, you know, they've, they've really embraced the importance of COVID vaccination, because they've got, obviously the fly-in fly-out people from around the world, and they need to protect themselves and protect their business. So we found models where we can use, you know, you know, your Santos of the world or your Newcrests of the world to bring vaccination into the province and assist the PHAs to roll out to different areas of the of the province as well. So, you know, some of the modalities in which we've introduced through lead partner mechanisms and coordinating partner mechanisms, I think can go a long way into improving where we are with routine immunisation, so while while the best case scenario is integration, we need to really think about how we integrate and whether it is the right time to to put COVID on onto an already stressed immunisation programme. So there is a transition plan back into the department. But with that transition plan there needs to be the department needs to be ready, we need to be ready to hand over. And obviously our PHAs need to understand and take ownership of the, you know, the challenge going forward. And like I said earlier, provinces are at different levels of the vaccination programmes. We have provinces that are, you know, absolute stars in in the way that they've vaccinated, and the way that they've communicated the COVID messaging, but then we've had, you know, provinces as well, who, who almost were reluctant, because it was such a challenge. So, you know, we've got different levels of of our programme that need to be considered before we try to normalise it. 

Dr Stephanie Williams 25:54

Api, I know that was an impossible question to ask you. But your answer was well worth posing the question. And I'm just struck by your insights and perspective from coming to this Vaccine Task Force months ago, maybe almost a year ago, and your openness to be thinking about how to evolve and be really listening and trying to understand and adjusting to the context in which you found yourself. There's obviously a long way to go, but I just want to thank you for joining us on the podcast today, for sharing some of those hard won insights around the challenges that you and the team faced and, and some of the challenges that you've laid out for the future. So thank you so much for your time today.

Mr Api Kassman 26:45

No problem, Stephanie. And thank you very much for paying a keen interest in what's happening in Papua New Guinea. And obviously, the fantastic support that has come through the Australian Government and continues to do so. Yeah, thank you. My pleasure to be here.

Dr Stephanie Williams 27:00

You've been listening to Mr. Api Kassman talk about challenges and learnings from the COVID vaccine deployment programme in PNG. We hope you enjoyed the conversation. I'm Stephanie Williams, Australia's Ambassador for Regional Health Security. In this third season of Contain This, we'll be bringing you insights, analyses and updates on what is shaping global health and health in our region. Importantly, we remain committed to bringing to this podcast voices of and from the Indo-Pacific region. We look forward to having your company on the next episode.  

Contained This is produced by the Indo Pacific Centre for Health Security. You can follow us on Twitter at @centrehealthsec.