Polio Transition Independent Monitoring Board Seventh Report - The struggle for progress: Does system strengthening always have to be slow? (October 2024)

Introduction

The fundamental challenge in implementing polio transition is that, while the overall purpose is quite clear, the complexity involved in reaching consensus on its precise goals, on how best to implement them, and finding agreed ways to measure progress has led, over recent years, to a constant process of revisiting and resetting this key programme.

The TIMB was established to oversee the polio transition process and provide independent evaluations of progress and recommendations for meeting the challenges and helping to shape the programmes of work.

The TIMB has produced six extensive reports over the last eight years, each time seeking to help to unravel these complexities and particularly to urge the polio partners to reach firm decisions on governance, on the timing of transfer of functions currently managed by the GPEI to new management arrangements, and on the extent to which polio transition should have an explicit role in strengthening health systems at country level to enable them to deliver a polio-free world.

Polio transition should not be seen as an “exit strategy,” where partners simply withdraw upon completion. Rather, it should be viewed as a maintenance and sustainability strategy designed to uphold the Polio Programme’s achievements and maintain its assets so that eradication gains are protected and integrated within broader health systems.

Such a perspective creates a clear distinction between handing-off responsibilities and creating a continuum where immunisation, surveillance, emergency response and primary healthcare systems progressively take on these roles without abrupt funding or support cessation. It helps to provide a healthy challenge to the premise that transition marks a definitive end to GPEI’s involvement and funding.

Early on in the concept of polio transition, it became clear that achieving the minimum requirement of ensuring sufficiently strong polio-essential functions within a country-led and funded post-GPEI world was far more complex than ever anticipated.

Part of the reason for this was the emergence of major global events of a very profound nature: the after-effects of the 2008 financial crisis, the COVID-19 pandemic and the repeated failures to meet any of the deadlines for interrupting wild poliovirus transmission in the 21st century so far.

The original World Health Assembly resolution, and the work of a heavily funded and tightly coordinated polio eradication programme, had been based on the assumption that the world would enter a new millennium free of the scourge of polio. It did not.

The other factor that started to push the polio transition programme off its intended path, and to cloud its original and inspiring polio legacy-orientated vision, was the difficult financial, geopolitical and environmental context of the countries that had been designated as priorities for transition work.

The fifth TIMB report, Building stronger resilience: The essential path to a polio-free world took particular care in trying to scope polio transition so that it captured both the polio epidemiology questions and the challenges of countries’ fluctuating capacity to deliver the programme’s goals. This report called for the polio transition process to be viewed and judged in three ways:

1. The strengths and weaknesses in organisation, governance and resource mobilisation.
2. The countries’ political, socioeconomic and conflict context and operating environments.
3. The current strength and readiness of the public health system to deliver optimum levels of immunity, run a high standard of surveillance, and identify outbreaks early and close them down quickly and effectively.

This is a formidable task for the countries to take on and deliver to the high public health standard required. Arguably, up until then, the polio transition work had concentrated on the first of the dimensions set out in the list above and less so on the second and third. Moreover, the early promise set out at the first TIMB meeting, that a polio transition programme, through the polio assets and expertise that it held, would be a catalyst for countries to speed up the development and strengthening of their entire health systems, seems now a forlorn hope.

Many countries, especially in sub-Saharan Africa, South Asia, and conflict-affected regions, are not yet ready to manage these functions independently. The challenge is further complicated by the extensive circulation of vaccine-derived poliovirus which is now causing much more paralytic polio than the wild poliovirus.

Even had the polio eradication work, led by the GPEI, delivered its goals in line with its strategic deadlines for interrupting poliovirus circulation, the world would not have been on the verge of eradicating wild poliovirus without a well-managed transition phase.

The period between achieving interrupting circulation of all polioviruses, and sustaining a polio-free world, poses significant challenges without the complexity that has come to surround it. Even with country stability and funding, the process of transitioning country-led health systems is complex, as governments must integrate polio-related functions, into their broader health infrastructure.

At the heart of the concerns that were expressed strongly and consistently by a wide range of delegates at the April 2023 TIMB meeting was the perceived ambiguity surrounding the meaning and purpose of polio transition.

In its subsequent, sixth and most recent report, Ambiguities and certainties: Meeting the diverse expectations of polio transition, published in July 2023, the TIMB noted that, while the technical goals of polio transition are clear, the broader vision for it and why it matters are not always kept at the forefront of discussions.

The report argued that this lack of clarity creates a situation where many countries, particularly those with weak health systems, do not fully understand the significance of the transition or their role in ensuring its success.

As the GPEI begins to wind down, the TIMB has repeatedly expressed the fear that many national health systems will see the end of poliovirus circulation as a conclusion, rather than a handover of responsibility.

The transition seems to be misunderstood as merely a technical adjustment, rather than a fundamental shift in the responsibility for maintaining a polio-free world.

This misunderstanding stems, in part, from the way that polio transition has been communicated. The TIMB points out that for many stakeholders, the language of “transition” itself is confusing.

In public health, transition often implies a handover of specific functions from one body to another, but in this case, the transition also involves a much broader shift. It encompasses not just the transfer of technical tasks but the long-term responsibility for maintaining and strengthening health systems, immunisation coverage, surveillance sensitivity, and emergency preparedness.

At its meetings, the TIMB detected that, for staff close to the frontline, polio transition has very negative connotations.

Mention of it can spark an emotional reaction. This is because it evokes the prospect of job losses and “pink slips”. The discussion of polio transition at the TIMB’s past meetings has always captured not only the technical aspects of polio eradication, but also the broader philosophical and structural considerations that have shaped the programme’s evolution over the years.

This seventh TIMB report, which follows the July 2024 meeting, assesses the current thinking of WHO and the polio partners on polio transition. It also judges the extent of progress with implementation.