The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme

"Maintaining and capitalising on the valuable tools created in this endeavour will involve the concerted attention of all stakeholders - donors, affected governments, civil society, and others - interested in furthering the causes of global disease detection and control and the health of world's children and women."

The Transition Independent Monitoring Board (TIMB) was created by the Global Polio Eradication Programme (GPEI) to monitor and guide the process of polio transition planning. Its role is to monitor progress toward the transition of polio assets - not only the tangible, but also the diverse knowledge and interventions created by countries and the GPEI as it sought to deliver polio vaccine to every child in the world over a 30-year period. In this first report, the TIMB provides an initial analysis of the priorities, plans, risks, and opportunities as the eradication of polio appears to be drawing closer.

The transition planning process initiated by the GPEI is predicated on four assumptions: firstly, that to the degree possible, countries will absorb the costs of sustaining polio assets within their public health systems; secondly, that countries will prepare national plans that map out the role polio assets play in their health systems and the deficits that will be created when the GPEI closes; thirdly, that the national plans will align with the targets laid out in the Global Vaccine Action Plan (GVAP) approved and endorsed by all World Health Organization (WHO) member states; and fourthly, that donors will be prepared to fill the gap. However, the TIMB finds that, beyond the world of polio leaders, academics, donors, and enthusiasts, there is little awareness or understanding of the enormity, complexity, and urgency of the action needed to deal effectively winding down of polio funding begun in 2017.

At its first meeting, the TIMB began the process of understanding the needs, pressures, risks, and prospects of individual countries that are dependent on polio resources. In speaking with representatives of India, the TIMB learned that, realising the value of its polio-funded infrastructure, the Government of India began looking for ways to preserve it even before its last case of polio in January 2011. It has established a transition planning group to develop a strategy for continuing the National Polio Surveillance Project (NPSP). State governments are exploring long-term support for the United Nations Children's Fund (UNICEF) social mobilisation network. Even with its head start compared with other countries, India still has not finalised a transition plan but, like other countries, is already facing funding declines.

After laying out the elements of transition, the TIMB explores some of the key lessons learned from polio eradication, noting that "[a] key strength of the GPEI has been its development of knowledge, expertise and experience in mobilising social and community support for vaccination. It has reached underserved and marginalised groups (including the populations in conflict zones) on an unprecedented scale. Techniques to track mobile and migrant groups are now very sophisticated. Country polio programmes have learned to engage constructively with traditional, religious, community, and civil society leaders to overcome resistance, hostility, and negative parental attitudes to the vaccine. Structures have been created for community mobilisation. They have enabled delivery of immunisation on a house-to-house basis. They have reached parents at special events, festive gatherings, cultural and religious occasions like weddings and shrines. The teams from UNICEF, and NGO [non-governmental organisation] consortia, have placed great emphasis on really understanding communities and using the knowledge gained to communicate effectively and to guide the approaches of frontline workers. Polio resources have often been used as a springboard for broader public health engagement of populations."

In addition, the TIMB points to the process of microplanning, which has become one of the flagship elements of polio eradication. This involves detailed mapping of communities, including the use of the Global Positioning System (GPS) and satellite photography. Local and countrywide accountability frameworks were built around the microplanning process. This accountability framework relies on a supervision process grounded in weekly reporting of "real time" data. Whilst in the field, supervisors make every effort to inform and engage local government leaders and district magistrates of a programme's status, while soliciting their support to correct deficiencies. Another example of local engagement is the Islamic Advisory Group, which is made up of well-respected scholars and clerics who have helped to overcome some of the religious and cultural objections to polio vaccine by local communities.

Ensuring that this type of knowledge generated and these lessons learned during polio eradication activities are shared with other health initiatives is part of the GPEI to transition planning so far. Not doing so carries risks; for example, it is not easy to communicate to donors the important role that technical functions like disease surveillance plays, yet the reduction of resources supporting polio eradication is a real threat to continuing and expanding vital surveillance networks globally.

The TIMB observes that the importance of country leadership for transition planning is at the heart of polio transition process: Each country has its own context and an existing pattern of public health services. That said, transition guidelines have been sent out to countries specifying in broad terms what they will need to do to maintain and mainstream the essential polio functions. Although countries are expected to adapt to the need they see in their country, the GPEI has set out six key milestones to help them move forward, including: raising awareness, establishing in-country coordination, gathering evidence for decision-making, generating strategic options, and developing a more detailed vision for the future. While most of the priority countries have moved forward with transition planning in some shape or form, few have yet finalised plans, according to the TIMB.

The TIMB sees the job of transition as involving seven outcome-oriented tracks of work. After outlining these, in the final narrative section, the TIMB identifies twelve main areas of work that they will be doing looking forward (e.g., engaging in discussions with NGOs to understand their viewpoints). The concluding pages offer data insights in the form of charts and graphs.