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A report commissioned by the independent monitoring board of the Global Polio Eradication Initiative on progress in Afghanistan, Nigeria and Pakistan - Review of polio endemic countries September 2018

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Despite progress towards eradication of wild poliovirus (WPV) in the three remaining endemic countries, transmission of the virus has continued in 2018. The Polio Oversight Board (POB) of the Global Polio Eradication Initiative (GPEI) asked the Independent Monitoring Board (IMB) to commission a review with the goal of identifying actions to help accelerate progress towards sustained interruption of WPV. The IMB commissioned a multi-disciplinary team to assess what is working well and what could be further strengthened; to identify any major constraints; and to make recommendations to the IMB and the POB for their consideration.

The team visited Afghanistan, Pakistan and Nigeria spending approximately 10 days in each country.
Team members spent half of each visit outside the capital cities travelling to some of the highest risk areas for WPV transmission. The team reviewed extensive documentation and interviewed key stakeholders including senior leadership, frontline workers, community members, and informants from other humanitarian organizations. In this report, the review team has attempted to highlight areas for improvement, but specific responses to the issues identified are best determined at the country level, by the respective governments and GPEI partner organizations.


Access limitations due to insecurity continue to represent the biggest threat to polio eradication and progress towards interrupting transmission has stalled. Afghanistan’s security situation is deteriorating and the number of cases has more than doubled compared to this time last year.
Pakistan has widespread circulation of WPV documented by positive environmental specimens but isn’t acting decisively on these findings. Whether or not poliovirus transmission continues in Boko Haram controlled areas of Nigeria is unknown.

Cross-cutting findings

Operating environment: The poliovirus has taken refuge in some of the most challenging and dynamic environments in the world. The resilience and dedication of the staff who work in these areas is extraordinary.

Access and security: Insecurity remains the overriding threat to the programme. Unless security related constraints are effectively addressed, the global effort cannot succeed.

Emergency culture: All three countries have prioritized polio eradication at the highest levels of government. However, the sense of urgency, flexibility, and local empowerment needed to address polio as a global public health emergency is not consistently evident.

Management and oversight: The complexity of the GPEI structure and the demands it creates for reporting, distracts country programmes from the preeminent mission of interrupting transmission.

Human resources: It is not evident that sufficient efforts are made to incentivize recruitment of the best staff and ensure the proper duty of care in insecure environments. In addition, the balance of national and international staff needs to be carefully considered to obtain the greatest possible access for programme monitoring.

Unmet basic needs and fatigue: Communities in the highest risk areas lack access to food, water, sanitation and basic health services. The resulting frustration leads to refusals and absent children among key populations. Eradication will be hard to achieve without effective advocacy and coordination to help ensure the basic needs of high-risk communities are met.

Community perceptions: Lingering mistrust in the programme, such as questions of government ownership, programme neutrality and vaccine safety, contributes to the number of missed children.

Routine immunization: Routine immunization coverage is extremely low in critical areas of each endemic country. There is increasing collaboration between polio and routine immunization programmes, but political will must be strengthened to raise coverage and support programme activities.

Data: All three countries have well established data monitoring systems. However, the countries are overburdened with external data requests and have limited time to use data to improve programme quality between rounds. In Pakistan and Afghanistan, inconsistency between epidemiology and monitoring data raises questions of data quality.

Finance: While an audit was not conducted as part of the review, there is no evidence of major areas of financial excess. Countries are implementing special initiatives to address perceived areas of risk. Prematurely reducing budgets prior to interrupting transmission threatens eradication.

Transition: Given the current situation, a focus on transition planning in Afghanistan and Pakistan is potentially distracting. In Nigeria, the pace of transition should be tailored to the circumstances in each state.

Surveillance: Well-established acute flaccid paralysis (AFP) surveillance systems exist and generally report high quality performance at the first sub-national level. Disaggregation of data shows challenges with indicators at lower levels. Extensive environmental surveillance is well established, and is critical to complement AFP surveillance.