Pakistan + 2 more

Independent Monitoring Board of the Global Polio Eradication Initiative, 18th Report

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The 17th IMB report, published in November 2019, followed the Board’s meeting to review the Polio Programme’s performance. The IMB found the Polio Programme at a critical point with the eradication process seriously under threat.

Wild poliovirus transmission in Pakistan was surging. A huge and unprecedented immunity gap had opened up in Afghanistan as a result of the Taliban denying the Polio Programme access to communities. Multiple type 2 vaccine-derived poliovirus outbreaks were sweeping across Africa on a scale not imagined when the switch from trivalent to bivalent oral polio vaccine took place in 2016.

The 17th IMB report described this situation as a crisis. It identified deep-seated root causes that had led the Polio Programme into such a slump in its performance. Many of these had been highlighted in previous IMB reports. However, because over recent years the polio numbers were broadly progressing in the right direction, an attitude of “almost there” meant that the problems had not been definitively resolved.

These problems included the politicisation of the oral polio vaccine. It was being used as a source of conflict between political parties and as a bargaining tool by interest groups and factions with influence on whether communities participated in the Polio Programme in Pakistan.

Communities most at risk of polio were often those with multiple social and economic deprivation and a lack of basic infrastructure such as water, sanitation and public health services. Hostility towards the oral polio vaccine had been growing in these communities for some considerable time.

This was being fuelled by: a resentment that government did nothing to help them, yet wanted them to accept the polio vaccine as a necessity; little understanding of why so many doses of the vaccine were required (multiple knocks on the door); and fears, rumours and suspicions that the vaccine was harmful to children.

In addition to these major political, social, and communications problems, there were also weaknesses in management and organisation at an operational level. The basic technical performance of the Polio Programme was not reaching the levels of best practice that had helped stop wild poliovirus transmission in other regions.

The findings and necessary action to address the crisis, identified by the 17th IMB report, were accepted by the Polio Oversight Board (POB) of the GPEI and by the governments of the polioendemic countries. However, within weeks the COVID-19 crisis had broken, and polio teams and resources were repurposed in the fight against the pandemic coronavirus.

It is essential that the Polio Programme remembers that, by the end of 2019, it stood on very shaky ground. There were massive challenges both in interrupting wild poliovirus transmission in the endemic areas and in managing many vaccinederived poliovirus outbreaks.

Cases of poliovirus had increased fivefold between 2018 and 2019. There was uncertainty and doubt surrounding the effectiveness of strategies and tools.

At the Polio Oversight Board meeting, that immediately followed the Abu Dhabi Pledging Conference, on 20 November 2019, donor countries made an unprecedented demand that the GPEI should review and reform its governance and accountability structures. This did not reflect a reduced determination by these donors to get the job done, but rather the depth of their concern that there was no clear end in sight for polio eradication, and a lack of clear accountability in a $1 billion a year spending programme.

Even before COVID-19, many donor countries’ overseas aid budgets were being heavily scrutinised. With the coronavirus’s savage impact on national economies, the case that polio dollars are safe in GPEI hands will, in future, need to be more convincingly made to the governments and taxpayers of these countries. At the same time, there is greater need for resources than originally planned.

Each year of failure to eradicate polio results in enormous health, opportunity, and economic costs. The budgetary needs of the programme are increasing steeply. They will increase further if vaccine-derived poliovirus outbreaks continue to occur on a wide scale. Also, conducting polio campaigns in a COVID-19 environment will be much slower, will need many more precautions (such as personal protective equipment), and, as a result, will be more expensive.

This 18th IMB Report follows videoconference meetings that the Board held with the GPEI Strategy Committee, donors, wider polio partners and the governments of the polioendemic countries on 29 and 30 June and 1 July 2020. The discussions were complex because they had to take account not only of the programmatic weaknesses and action needed to transform them before COVID-19 struck, but how to build the impact of COVID-19 into the GPEI’s ongoing strategic approach to polio eradication.

The conversations also had to explore whether the period of pause and reflection, imposed on the Polio Programme by COVID-19, had caused the leadership of the Polio Programme to think differently about the path to eradication.