The euphoria surrounding Pakistan's polio program turned out to be pretty ephemeral with the resurgence of polio cases in North Waziristan, which now stand at 12-- this, from the same district in northwestern Khyber Pakhtunkhwa province, against just one case in Afghanistan which is the only other endemic country. The total number of polio cases in Pakistan this year now stands at 14.
The resurgence of cases in Malawi, Mozambique, the UK and now the US, which were declared polio-free a decade ago, should raise alarm bells in global polio eradication programs everywhere.
But countries like Somalia, South Sudan, Sierra Leone and the Democratic Republic of Congo with poorer health indicators and dysfunctional health and governance systems succeeded in eradicating polio while Pakistan still struggles, and key reasons have surfaced to explain why.
Polio is now intertwined within the social, anthropological, cultural and humanitarian awareness of Pakistanis, and in many ways its eradication is a battle of hearts and minds. The absence of vision and strategic depth at the highest levels of government is ultimately the most damaging blow to the fight.
The program now needs to navigate uncharted territory. It needs to be analyzed innovatively and academically. As it stands, the program’s management structure doesn’t fit in with its multi-stakeholder and multi-million-dollar program. The structure remains an “inverted pyramid” a top-heavy one, in terms of decision making and incentives, contrary to the needs of a grassroots program of this scale.
A just and equitable accountability system is largely missing from the program architecture. The private sector which could plug in some vital gaps hasn’t been adequately tapped. The absence of a strategic balance between leadership, management and technical domains is a critical blind spot.
For one, there are hidden refusals. Vaccination teams due to a lack of motivation and the communities they serve, collude on marking children as vaccinated without actually vaccinating them.
There is no doubt that the work environment for Front Level Workers (FLW) for various reasons is harsh and inconducive. There is not enough done to motivate FLW’s in these difficult scenarios, and this is by far the biggest reason for the program’s failures.
Dr. Nadeem Jan
Routine immunizations have remained stagnant in high-risk areas like North Waziristan and Southern KP. Despite some serious efforts, there is still a discrepancy between operations and communications and the constant contextualization required to win minds and hearts is missing.
Refusals keep popping up, and organized community boycotts are used as bargaining chips-- but the program remains visibly devoid of a long-term strategic solution.
‘One-size-fits-all’ strategies and stereotyping raise questions about the program’s lesson learning capacity.
There is no doubt that the work environment for Front Level Workers (FLW) for various reasons is harsh and inconducive. There is not enough done to motivate the FLW’s in these difficult scenarios, and this is by far the bigger reason for the program’s failures.
In the backdrop of all this, there is a dire need for a program rethink.
To begin with, the government should create a broad-based forum of neutral experts from the public health and development sectors, media and academia to work as a strategic advisory committee. This forum could develop a real national polio narrative so the big scheme of things can be modified.
A national round table on polio eradication- participated in by all mainstream political parties- would be another step forward. Provincial Emergency Operation Centers (EOC’s) must be empowered to decide routine operational issues at the minimum. It is imperative to establish provincial hubs for innovation and research in each province. Integrating routine immunizations in all phases of the program cycle and creating a meaningful synergy between the two could prove to be a win-win.
For enhancing the motivation of FLW’s, performance-based recognition and career pathways are designed so this cadre is optimally utilized in polio and beyond.
The booming private sector should be strategically engaged in areas of research, advocacy, demand creation and independent monitoring. The new program focus should shift to cost-effectiveness, quality and impact rather than processes, quantity and business as usual.
Generating a fine balance between quantity and quality, the campaign spree should be minimized to 3 to 5 rounds per annum, supplemented by IPV and OPV vaccination rounds as needed. The new nOPV vaccine is a more stable vaccine and the program should use this in outbreak zones as available.
To attain wider community acceptability, the pilot integrated health services package should be extended to medium-risk Union Councils (UC) and other areas of high importance. At the UC level, an inclusive ‘Refusal Conversion’ committee should be established and incentivized to bring sustainable dividends. Innovation is key. Brand ambassadors for each locality should be identified and deployed into high-risk groups. More neutral avenues like the Pakistan Paediatrics Association, the National Ulema and Mashaikh Council, local community committees, and trade unions should be engaged to amplify the program’s voice.
It’s pivotal that all communications are guided by a challenge mapping exercise that can fine-tune the granular specifics.
Creating a pragmatic balance between technical and human factors is the best way forward. In innovation and out-of-the-box (as well as out-of-the-comfort-zone) solutions, lies the glory and success of polio eradication in Pakistan.
– The author is a recognised public policy & health expert of global repute, who has had careers with the UN, WHO, USAID, World Bank and various governments.
He tweets at @DrNadeemjan
