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CLOSING IN ON ZERO: ADAPTING TO COMPLEXITY AND RISK ON THE PATH TO END POLIO, SEPTEMBER 2023
INTRODUCTION
This is the 22nd report of the Independent Monitoring Board (IMB) for the Global Polio Eradication Initiative (GPEI). The Board has operated over the past 13 years. It has assessed and analysed progress with polio eradication and made recommendations to the Polio Oversight Board (POB) and, through this body, to the Polio Programme and to the wider partnership that has been working to achieve polio eradication.
The IMB is not a technical body. It analyses the weaknesses and deficits in the Polio Programme’s functioning at country, national and global level. It invites country delegations to its meetings to explain and account for their performance. Such delegations have usually been led by a health minister and senior government officials and are accompanied by the country’s senior polio technical team members.
At times, IMB reports have made uncomfortable reading for the countries still struggling to interrupt poliovirus circulation, and for the leaders of the Polio Programme at global level. The IMB’s independent “without fear or favour” and “speaking truth to power” way of operating has helped to increase accountability for polio eradication and to focus attention on the need to manage performance tightly. Both of these essential management functions – accountability and performance management – are not inherent features of most global health programmes.
Over the years, an enormously valuable role in assessing the Polio Programme’s progress, complementary to the IMB’s, has been played by the Technical Advisory Groups (TAGs). The groups remain an essential part of the Polio Programme’s governance structure. They are advisory to country programmes and their membership comprises global and national experts. Unlike the IMB, their secretariat is provided by the GPEI partnership.
The IMB’s perspective on polio eradication now spans more than a decade and has involved deep exploration of the reasons for the lack of programmatic progress. The roots of the Polio Programme are in a technical, communicable disease control tradition with well-tried, evidence-based tools coupled with clear and well-established data sets.
From the outset, the IMB has endorsed the great importance of excellence in technical delivery but has also pressed very strongly for the Polio Programme to take account of the wider determinants of its performance. These can broadly be described as the “human factors” in polio eradication.
When the IMB was formed, more than 90% of the burden of paralytic polio in the world had been reduced, but for years there had been little change. This performance was a deep concern and reflected three things. First, many of the human factors areas (e.g. communities’ resistance, political misalignment, male-dominated vaccination teams) had become mission-critical, yet the Polio Programme had not come to terms with their importance. Second, the operating environment in the remaining polio countries had become much more complex and challenging, and what had been successful in the past in other places was not working. Third, the programme was clinging too tightly to a vertical delivery ethos and failing to see the value of a mixed methods style of working and bringing in some integrated approaches. This tendency towards intransigence was coupled with a highly positive public “almost there” narrative, that was close to magical thinking.
In 2018, the Polio Programme, emboldened by positive poliovirus epidemiology, declared itself on the brink of interrupting wild poliovirus circulation. Around this time, an IMB-commissioned field visit to the endemic countries by experts recorded a long list of serious concerns. This dissonance of perspectives ended badly, with large outbreaks of wild poliovirus in Pakistan and Afghanistan and an intercontinental surge, a few years later, of almost a thousand vaccine-derived poliovirus cases with its epicentre in Nigeria (which had recently been certified polio-free). The latter confirmed what had been clear for some time: vaccine-derived poliovirus needs to be regarded as having parity with the wild poliovirus in its potential to harm children.
The evolution, over the last decade, of a Polio Programme that has failed to meet the numerous deadlines that have been set, carries a clear lesson for the current situation, where once again, leaders of the Polio Programme believe that interruption of poliovirus transmission looks possible. That lesson is that polio will only be eradicated if the Polio Programme addresses all the domains requiring strategic and operational focus: technical; community engagement; national and local political commitment and alignment; and geopolitics.
As will be apparent from reading this 22nd IMB report, every single one of these four domains contains a complex range of factors, all of which influence the performance of the polio eradication programme. A Polio Programme alive to their importance and addressing them through careful scrutiny of data, open and inclusive discussion and planning, combined with carefully structured action, will be on the right path to succeed. Alternatively, a Polio Programme that is selective in what it tackles, dismissive of the need to work on the human factors, and ducking the most difficult, intractable obstacles will be doomed to keep revisiting failure.