The CORE Group Polio Project: An Overview of Its History and Its Contributions to the Global Polio Eradication Initiative

"From the start, the CGPP focused on improving the quality of [polio immunisation] campaigns through the collection of reliable coverage data, better micro-planning and logistical support, and strong community engagement to promote positive participation and acceptance on the part of the community members."

The first in a series of articles describing the work of the CORE Group Polio Project (CGPP), accessible through Related Summaries, below, this article offers an overview of the CGPP's work to engage more than 40 non-governmental organisations (NGOs) in 11 countries over 20 years in the global effort to eradicate polio. The CORE Group is an association of NGOs working with communities around the world to improve health. The CGPP was established in 1999 to promote greater NGO engagement in community health, making it possible for the United States Agency for International Development (USAID) to channel grants to them to work on polio eradication in high-risk areas.

Tracing the history of the establishment of the Global Polio Eradication Initiative (GPEI) in 1988, the authors explain how it is that USAID, the United Nations Children's Fund (UNICEF), and the World Health Organization (WHO) came to recognise, about 10 years into the GPEI's work, the critical importance of identifying high-risk areas, developing focused social mobilisation activities to increase the coverage of polio immunisation and other basic immunisations, and implementing high-quality surveillance to identify new outbreaks.

In outlining the first decade of the CGPP, the article explains the development of a strategy for how the NGOs should plan and design a polio project. The first countries to start a national CGPP were Uganda, Angola, India, Nepal, Bangladesh, and, later, Ethiopia. The in-country CGPP focused on community-based surveillance and on expanding vaccination coverage through social mobilisation, logistical support, planning, and independent campaign monitoring for both routine immunisation services and special immunisation campaigns. This early experience set the stage for later CGPP project launches in Nigeria, Kenya, Somalia, South Sudan, and Afghanistan. (Examples of specific in-country activities of the CGPP that were carried out between 1999 and 2008 are shown in Figure 1 of the article.) The CGPP developed a secretariat model, which is elucidated in the article, to establish better collaboration and coordination between numerous NGO partners in polio eradication and between various levels of engagement - from the community to the district, provincial, national, regional, and global levels.

The authors explain that one of the key strategies of the CGPP from its inception has been the use of community health workers, also sometimes called community mobilisers, to educate mothers and youth about the reasons for eradicating wild poliovirus (WPV) and how its transmission can be stopped. In many cases, community health workers were already conducting behaviour change education in the community as part of child survival projects managed by CORE Group member NGOs. Thus, adding polio messages to their existing activities required minimal adaptation. (Also, whenever possible, NGOs shared training materials, job aids, reporting formats, and other materials, thus reducing duplication and overall costs. An example of such a material, shown above, is the "Butterfly Booklet", developed by the CGPP in India and distributed to influential persons in the community to remind them of the importance of disseminating "polio plus" messages.) CGPP health workers, NGO field staff, and government health workers sat together and studied district-level health data to determine where to canvas households and direct their mobilisation efforts. The community health workers in some localities were also taught to conduct community-based acute flaccid paralysis (AFP) surveillance. "NGO staff and community health workers were creative and persistent in putting into practice the commitment to reach every un-vaccinated child in communities where there was endemic WPV or very low immunization coverage to decrease the build-up of susceptible cases and stop transmission of WPV."

This period of the CGPP's history (1999-2008) also saw the development of a community engagement strategy, as evidenced, for example, by the India CGPP's collaboration with UNICEF to establish the Social Mobilisation Network (SMNet) in the state of Uttar Pradesh. The success of this strategy in India promoted its adoption in other countries such as Nigeria, Pakistan, and Afghanistan. In that vein: "An evaluation...of the first decade of CGPP activities concluded that the CGPP had made a strong contribution to global polio eradication efforts through its local community presence in high-risk areas, its training of local mobilizers to assist in polio eradication efforts, and its participation in polio eradication programming (particularly at the local level)."

The work of the CGPP during the second decade (2009-2018) was designed to be flexible so that international NGOs and their local NGO partners could respond to changing needs on the ground for support of polio eradication. During this period, the CGPP closed programmes in Nepal, Bangladesh, and Angola following sustained interruption of WPV, and it launched new initiatives in Nigeria, South Sudan, Kenya, Somalia, Uganda, and Afghanistan in response to the needs of the GPEI. Several evaluations have been conducted of CGPP work during this time frame in these countries, and data are shared in the article. To cite only one example: Published findings of evaluations of CGPP activities in Uttar Pradesh, India, have documented the importance of mosque announcements in improved campaign performance in high-risk areas and have found that in previously low-coverage, hard-to-reach, and resistant areas where SMNet was operating, the coverage was as high as or higher than in non-SMNet areas.

In evaluating the contribution of the CGPP to the GPEI, the authors point to the assessment by several technical advisors for the GPEI that communications and community engagement to mobilise social and community support for vaccination have been central to the Initiative, and that this is one of the important legacies of the GPEI for future global health work. As this article has attempted to show, CGPP's work to build social support for vaccination has been a hallmark of its work. According to the authors, this can largely be attributed to 4 strengths of NGOs: (i) they are present and active at the community level; (ii) they are willing to take on new activities; (iii) they have a commitment to producing and sharing high-quality, reliable data, even if it conflicts with data obtained through official governmental channels; and (iv) they are willing to be accountable to their donors and to their communities.

"Many of the innovations and approaches that the CGPP helped to develop are now being replicated by governments and international agencies to tackle other public health priorities in underserved and marginalized communities around the world."