Another Chance: Don't Let It Slip Away - Twentieth Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

"The performance coming out of the COVID-19 programmatic lockdown has given the Polio Programme another chance to finish the job it started more than 30 years ago. All its many supporters hope that this time it doesn't blow it."

The latter part of 2020 and the first half of 2021 saw the resumption of polio campaigns that had been suspended due to the COVID-19 pandemic. In that context, this report by the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) assesses progress, offers advice, and highlights certain weaknesses in the response to the recommended action in the last (19th) IMB report (see Related Summaries, below), given that most of this action was designed to address deep-seated barriers to polio eradication.

The IMB heard and discussed a progress report from Dr. Faisal Sultan, Federal Health Minister of Pakistan, one of the two remaining polio-endemic countries. Among his comments, the minister said he was hearing less about community resistance to the oral polio vaccine (OPV) and more about the involvement of community and religious leaders to address mistrust. He pointed out that vaccine refusals had steadily reduced with each campaign. In addition, the polio programme in Pakistan has begun a new form of research to understand reasons for missed children. It is called "KAP plus E": knowledge, attitudes, practices, plus experiences. The "E" aspect reflects on caregivers' past relationships with the polio programme. It is a mixed-methods study, using qualitative and quantitative approaches.

Furthermore, Pakistan's polio programme will begin to get further and deeper insights from the anthropologist who is working in all four polio-affected provinces. She is conducting a new wave of research amongst communities to develop ethnographic studies of the reasons behind missed children. This is appropriate, as the "IMB has long been frustrated by the Polio Programme's failure to mainstream social data at all levels in its work. It is now paying the price as large numbers of persistently missed children stand in the way of success. The number of missed children in the 2021 vaccination rounds is still higher than it was in 2018 and 2019."

The IMB also met with each of the four Pakistan provincial government teams (Sindh, Khyber Pakhtunkhwa (KP), Balochistan, and Punjab) in mid-May 2021; a summary account of each conversation is provided in the IMB report. For example, in Sindh, as of mid-May 2021, there had been no wild poliovirus (WPV) cases reported since July 2020. The health minister attributed gains to new communication initiatives and interventions, together with a greater focus on the high-risk districts. Examples include: increased involvement of union council secretaries and local influencers; extensive social profiling and mapping of refusals (followed by engagement in communication activities and conversion of refusals to OPV acceptance by Pashtun tribal leaders and religious, political, and other local "notables"); a more positive media stance on polio; engagement with public representatives and community-level influencers, especially Pashtun influencers; and alliance building with all sectors (e.g., the Pakistan Islamic Medical Association) to create an enabling environment.

However, as the IMB explains, "When the June 2021 vaccination campaign quality assessment data became available, they showed a variable picture, sometimes at odds with the compelling statements of progress made at the IMB meeting." In light of these findings, each of the provincial polio programmes "is now focusing strongly on the factors leading children to be missed in vaccination campaigns and going deeper into the root causes", as the KAP plus E initiative on the part of the Sindh polio programme, discussed above, exemplifies. "They have worked in depth on refusals and discovered how many are misconception-based and, if they are, to identify the nature of misconception, and whether there is any religious background to it....Each province is then using the detailed profiling data they have gathered in social mobilisation and communication activities."

Along those lines, "The most promising work seems to be where refusals are matched directly to an influential person from their own community. This use of influencers, in some cases highly tribe-specific, is happening to a greater or lesser degree in all the provincial Polio Programmes. For example, the Sindh provincial Polio Programme has started some good work in Karachi. For the first time, they are mapping refusals by tribe and language. The importance of identifying these tribal differences is that action can be sensitively tuned to cultural identity and choice of influencer....Social profiling also helps to identify areas where social mobilisers are needed, and reveal, for example, where more Pashto-speaking people are required. Local NGOs [non-governmental organisations] and the Pashtun population in that area can help in this regard."

In its past few reports, the IMB had recommended that the polio programme channel resources to the sanitary infrastructure and other services in the 40 super-high-risk union councils (SHRUCs) in Pakistan, thereby reducing poliovirus-friendly environments, helping communities, and creating goodwill. Having noted slow progress on implementing these recommendations, the IMB asked the polio programme for a comprehensive assessment of the situation. But it was clear to the IMB that the programme itself had initiated no systematic monitoring and open reporting process. The IMB was especially disappointed in the poor progress in water and sanitation and the apparent lack of data on what the target is for improved water and sanitation points.

Turning to the other polio-endemic country, health minister Dr. Wahid Majrooh led the Afghanistan polio programme team in discussion with the IMB at its 20th meeting. Among his reflections were that the programme has made positive interventions with communities, including cluster-based community engagement activities supporting the greater involvement of influencers, community elders, schoolteachers, politicians, and the media in vulnerable provinces. Also, efforts are being made to ensure gender equity at all levels of the programme. For example, in Kandahar City, a programme to recruit female frontline workers gradually increased their proportion in teams. However, the number of female workers declined after the killings of three female polio workers in Jalalabad City in March 2021.

More broadly, the IMB's assessment is that, while improvement of the polio epidemiology in Afghanistan is encouraging, the continuing inaccessibility (e.g., due to the Taliban's presence) of 3.5-5 million children is problematic for interrupting poliovirus circulation. In short: "The prospect of interrupting poliovirus circulation in Afghanistan is clouded by the worrying uncertainty of the geopolitical context." Following the IMB's recommendations, which have urged the Afghanistan polio programme to make a more concerted effort and take a different approach to reaching children in the inaccessible areas, some progress has been made. Notably, negotiations to secure mosque-to-mosque vaccination campaigns in inaccessible areas have advanced.

The IMB reports that a regional subcommittee for polio eradication and outbreak response has been constituted, with the first meeting held on March 16 2021. Its main objectives are to foster more intensive and collective regional actions on polio eradication. For example, it will work to involve all relevant cultural, political, religious, and civil society partners in any outbreak-affected country and, in so doing, to promote the political and social neutrality, as well as acceptance, of the polio eradication programme.

Delving into the issue of outbreaks of vaccine-derived poliovirus (VDPV), of which there were 240 cases in the 6-month period before the IMB met in mid-May 2021, the IMB notes that the scale and multinational nature of the outbreaks was "a moment of crisis for the global Polio Programme". The IMB discusses the importance of adopting a regionally coordinated response, not just country by country, to reduce the risk of the poliovirus flowing across borders. Ultimately: "The experience of epidemics of vaccine-derived poliovirus cases arising from the type 2 oral polio vaccines means that work to develop novel oral polio vaccines types 1 and 3 should be advanced, as well as studies to determine if there are problems combining these new vaccines."

With regard to the GPEI's management and leadership culture, the IMB stresses: "[I]t is essential that the Polio Programme at every level encourages complete openness and constant feedback. Front-line staff should be praised for raising concerns and insights about the delivery of their local programme, even if they represent difficult problems for their supervisors. It is down to the Polio Programme's leaders to promote and sustain such a culture at all times."

Other areas where the IMB has ongoing concerns, with advice on how to address them, include:

• Looking again at the frequency and quality of polio vaccine campaigns in each Pakistan province;
• Engaging, empowering, and staying close to the civil administration in the Pakistan provinces;
• Diving deeper in terms of analysis and solutions to reduce the numbers of "still missed" children in the Pakistan provinces and urban hotspots (e.g., by matching an influencer or respected community or religious leader to the precise tribal origin of the family and community);
• Maintaining progress on the GPEI gender equality strategy;
• Sorting out the poor and patchy progress in the agreed programme to transform the sanitary infrastructure of SHRUCs in Pakistan;
• Recalibrating the relationship between the global polio partners and the Pakistan national and provincial polio programmes to empower and add value to the latter's work;
• Forming a strong and dynamic partnership with the World Bank to ensure that the Global Financing Facility investment in Pakistan goes to the communities with the greatest need; and
• Instilling greater urgency and a more consistent strategic approach to closing down polio outbreaks and implementing coordinated, large-scale campaigns for the novel oral polio vaccine (nOPV).