Ted Chaiban on vaccinating the world

By Carmen Paun, Erin Schumaker, Ben Leonard and Ruth Reader

Ted Chaiban led the effort to vaccinate people in the world's poorest countries for Covid-19. | UNICEF, Senegal

Ted Chaiban, a seasoned UNICEF executive, has led the Covid-19 Vaccine Delivery Partnership, which has sought to vaccinate the most at-risk people in the world’s most impoverished countries.

The partners — UNICEF, the World Health Organization, Gavi and the World Bank, among others — plan to wind down the effort in June amid declining interest in the shots. Chaiban spoke with Carmen about what has worked to get more people vaccinated and what needs to happen next.

This interview has been edited for length and clarity.

When you started in this role, there were 34 countries with Covid-19 vaccination rates under 10 percent. How did you manage to bring the rates up in most of them?

Political advocacy, basically engaging with countries and indicating that while there are many other priorities, and while Omicron had changed risk perception, it was still important to focus on vaccinating the population against Covid.

We emphasized the importance of reaching country milestones and focusing on high-priority groups, or specifically, the elderly above 60, health care and other frontline workers and people with comorbidities.

In places like Tanzania, Madagascar, Malawi, that dialogue helped. Now, Tanzania is reaching 50 percent coverage level.

How did you pay for it?

Quick impact funding, so basically making money available quickly to different countries. Over the year, we've gotten over $143 million into specific countries to fund specific vaccination campaigns to raise vaccine coverage levels.

One of the first examples of this was in Chad, where there was a new minister of health. It was right before Ramadan. They had expiring vaccines. We got $5 million into Chad and they were able to do a vaccination campaign that, at the time, doubled their vaccine coverage level to 12 percent.

Overall, we were able to support the countries to vaccinate 139 million additional people.

How did you approach the distribution challenge in countries that don’t have infrastructure?

We used our missions to line up partners to address those technical needs.

An example of that is Ethiopia, which used World Bank resources to bring an additional 5,000 staff on surge. Into 2024, that personnel will still be available, both for the Covid response but also other primary health care priorities. And the ministry of health in Ethiopia is slowly finding ways to have part of those costs moved on to the national budget, so it’s sustainable and those capacities are maintained within the system.

What’s the outlook for countries that remain under the 10 percent vaccination rate?

There are still nine countries below 10 percent, but two of them never joined [the global vaccine equity effort] COVAX: Eritrea and North Korea.

Of the seven countries that did join COVAX, five are dealing with major emergencies. Those are places like Haiti, Burundi, Yemen, the Democratic Republic of the Congo and Madagascar. Then you got Papua New Guinea and Senegal.

Senegal is now at 8 percent, and we expect they will cross 10 percent.

We’re trying to leverage humanitarian architecture and humanitarian partners to reach vulnerable populations. So we're doing this in DR Congo, in Mali and South Sudan.

We also have countries that have done remarkably well under the circumstances. The Central African Republic is now at 40 percent coverage. Somalia, despite dealing with massive food insecurities, is at 37 percent coverage. Afghanistan, which was at 9 percent at the beginning of last year, is now at 28 percent coverage.

Why is the partnership ending in June?

As countries are going from an acute phase of addressing the pandemic to an ongoing phase where the dominant strategy will increasingly be one of integrating Covid-19 into primary health care services, a vertical approach to Covid-19 vaccination has diminishing returns.

What are the lessons learned from this effort?

There needs to be much more production of medical countermeasures in Africa, in Asia and Latin America. And it’s not about Covid. This is about measles. It’s about polio. It’s about pneumonia. It’s about protective equipment.

The second point I would make: With a couple of exceptions, it’s not a surprise that while we’ve got a 64 percent coverage rate for vaccination against Covid globally, lower-income countries are at 23 percent.

It’s essential that we focus on strengthening community health systems and paying and protecting community health workers. If we end up with 10 or 12 more countries after Covid that have a more sustainable basis for the community health system, then we'll be in better shape next time.

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Private equity firms are buying physician practices and hiring more nurses and physician assistants. | Photo by Christopher Furlong/Getty Images

When private equity firms acquire medical practices, they rely more heavily on physician assistants and nurse practitioners to care for patients than doctor-owned practices do, a new study suggests.

“A goal is to profit maximize,” said Jane Zhu, an author of the new study, primary care doctor and an assistant professor at Oregon Health & Science University.

That doesn’t necessarily mean private equity firms are reducing the number of doctors on staff, but upping the percentage of physician assistants and nurse practitioners could be a way for clinics to see more patients and cut costs simultaneously.

The study, published Monday in the journal Health Affairs, looked at 213 private equity-backed dermatology, ophthalmology and gastroenterology practices — chosen because they’re high-volume, office-based specialties in which private equity firms have high penetration — and compared them with 995 doctor-owned practices in the same specialties.

“We’re facing huge changes in the practice environment,” Zhu said. Private equity investment, she said, is shedding light on those changes, which are especially relevant to younger doctors still pondering their career trajectories.

The study also found: 

— Compared with doctor-owned practices, individual clinicians were more likely to both enter and leave private equity-backed practices, which suggests higher workforce turnover. It’s possible, however, that doctors who join and leave private equity-funded practices are dissatisfied with general workplace pressures, like burnout, stress or poor work-life balance.

Why it matters: Private equity firms poured billions into the U.S. health care system in recent years, more than doubling health care investments from $66 billion to $151 billion between 2020 and 2021, according to management consulting firm Bain & Company.

Private equity may offer stability to doctors facing a competitive health care market and relief from time-consuming administrative tasks.

Practices that rely more on physician assistants and nurse practitioners could expand access to care in areas where doctors are in short supply. The study didn’t look at whether patient care suffered after private equity investment. Study authors wrote that “a more stable workforce is associated with better health outcomes for patients, improved quality metrics, and reduced resource use.”

Big picture: Because the study analyzed 2014–2019 data, the findings don’t account for major changes in the health care system wrought by the Covid-19 pandemic. A decline in patient visits, canceled or postponed procedures and health care workers leaving the field put practices in a precarious financial position.

That could mean more opportunities for private equity to invest. “That increased the incentives for practices to sell to private equity,” Zhu said, adding, “The data that we know about in the industry reports are suggesting that [private equity] growth in health care has only increased during Covid, not decreased.”

Patients seeking mental health care made heavy use of virtual visits during the first year of the Covid pandemic. | Wilfredo Lee/AP Photo

If the convenience of telehealth prompts patients to schedule more overall visits, it could drive up health care costs and make the government and insurers less willing to permit virtual visits.

But a new study based on employer-sponsored insurer data published in JAMA Health Forum has reassuring news for telehealth advocates. In 2020, when many people were meeting with their doctors online, overall mental health care usage ticked up only “slight[ly],” the researchers from the RAND Corporation and Castlight Health found.

As the Covid pandemic took hold, virtual visits helped to more than replace plummeting in-person visits for anxiety disorders and kept visits for other mental health conditions steady.

Some other findings: 

— People in rural counties far from metropolitan areas were less likely to use telehealth. The authors said that might “be a result of telehealth services failing to reach remote, lower-income communities throughout the U.S.”

— Younger adults (below age 46) were more likely than older adults (46 or above) to use telehealth. The authors said this could be because of differences in digital literacy.

Takeaways: The researchers, citing previous studies, said mental health care use steadily rose throughout the pandemic, perhaps due to a spike in anxiety generally, not necessarily because of expanded telehealth access.

They found that women sought care for anxiety disorders more often than men did. Women might have been more likely to use telehealth because of “stressors that may have disproportionately been placed on females” like taking care of children who weren’t in school, they said.

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