Global Polio Eradication Initiative: Lessons Learned and Legacy

"It is important to document the lessons learned from polio eradication, especially because it is one of the largest ever global health initiatives. The health community has an obligation to ensure that these lessons and the knowledge generated are shared and contribute to real, sustained changes in our approach to global health."

This article summarises 10 lessons learned from the Global Polio Eradication Initiative (GPEI) as part of the efforts called for in the Polio Eradication and Endgame Strategic Plan 2013-2018's call to plan the GPEI's legacy. During its more than 25 years of operations, the GPEI has: "mobilized and trained millions of volunteers, social mobilisers and health workers; accessed households untouched by other health initiatives; mapped and brought health interventions to chronically neglected and underserved communities; and established a standardized, real-time global surveillance and response capacity." There are 3 principal aspects of the polio legacy work: (i) mainstreaming essential polio eradication functions, such as communication, into ongoing public health programmes; (ii) ensuring that the knowledge generated and lessons learned are documented and shared; and (iii) where feasible, desirable, and appropriate, transitioning the capacities, processes, and assets, including human resources, that the GPEI has created and engaged to support other health priorities.

The lessons of GPEI fall into 5 general categories as outlined here: (i) mobilising political and social support, (ii) strategic planning and policy development, (iii) partnership management and donor coordination, (iv) programme operations and tactics, and (v) oversight and independent monitoring. In sum, the lessons include (footnote numbers removed from extracts):

1. "Communications and Community Engagement: Mobilizing Social and Community Support for Vaccination - ...Through this process of mobilizing communities large and small, the polio program has developed the expertise to overcome the logistic, geographic, social, political, cultural, ethnic, gender, and other barriers to working with the most-marginalized, most-deprived, and, often, most–security-compromised children and communities...The characteristics and innovations developed to build social support for vaccination, include the following:
   • Coordinating communications to support a global and national public health goal, as well as the 'relentless pursuit of the missed child' at local levels
   • Identifying individuals, themes, and social pillars that could unify and motivate diverse population groups for a common goal
   • Engaging with the media as a critical partner in raising awareness, holding stakeholders publically accountable for vaccination, and motivating leaders and communities for greater progress
   • Mobilizing communities house-by-house on a grand scale to accept oral poliovirus vaccine (OPV) and other health interventions, including vitamin A supplementation, measles vaccination, antihelminthic administration, and soap, bed net, and oral rehydration solution packet distribution
   • Creating detailed neighborhood vaccination team micro-plans and maps, including the identification of so-called pro-OPV influencers and supporters to help address vaccine hesitancy or resistance at the point of care
   • Tracking of mobile and migrant groups and communicating to these groups while they are in transit
   • Reaching families with information and vaccine, even when they are out of the house during campaign days; mobilizing parents at social, cultural and religious events such as weddings, mazars, shrines, and melas (festivals)
   • Using traditional, religious, community and civil society leaders and structures for community mobilization."
2. "Communications and Community Engagement: Using Targeted Disease Initiatives as a Springboard for Broader Health Communication - ...Promoting the promise of additional health and water services has opened new doors, leading to additional children now vaccinated against polio and to the discovery of those children most invisible to all social services....Communicating for polio vaccination has served as a springboard for broader public health outcomes by
   • Investing in interpersonal skills, management, and motivation of all frontline workers
   • Tracking and counseling pregnant mothers on prenatal health and following up on 0-dose polio vaccination and neonatal health and routine immunization
   • Conducting targeted communication and outreach for routine immunization sessions and advocating for the improvement of sessions that were poorly attended, managed, and stocked
   • Advocating for better delivery of health services that meet social, cultural, and gender-based needs of communities they target
   • Promoting and delivering additional health interventions besides OPV to strengthen trust where feasible, including de-worming medicines, vitamin A supplements, measles vaccine, sanitation services, bed nets, and routine immunization
   • Building trust for OPV in inaccessible or insecure communities through the hosting of health camps."
3. "The Value of an Advanced, State-of-the-Art Global, Regional, and National Laboratory Network" - For example: "Provision of timely data on a weekly basis via the tiered structure (national, regional reference, and global specialized reference laboratories) of the network, which has become the model for other laboratory networks."
4. "Real-time Disease Surveillance and Response Capacity, Data Analysis, and Immunization Program Monitoring" - For example: "Creation of a weekly global, regional and country World Wide Web–based reporting system with mapping of individual cases that is publicly available and unprecedented in scope."
5. "Addressing Strategy Implementation in Conflict-Affected Areas and the Risks of International Spread to Previously Polio-Free Countries" - For example, the GPEI: "uses the World Health Assembly, other forums, and (recently) the International Health Regulations to persuade low-performing countries to increase their commitments and improve the quality of program performance."
6. "Essential Need for a Program of Research and Innovation" - "...This experience has demonstrated the central and important role of research and innovation in any initiative for overcoming program setbacks and leading to a successful outcome of the initiative. Innovative problem solving is required both from the bottom up as well as the top down..."
7. "Partnership Coordination, Advocacy, and Resource Mobilization" - "An essential best-practices component of the GPEI has been the cross-agency coordination of an effective advocacy agenda that was central to the eventual endorsement of and crucial support to the GPEI by political bodies such as the African Union, the Organization of Islamic Cooperation, the Commonwealth, and especially the Group of Eight....Among the characteristics and innovations are the following:
   • Professionally planned and guided advocacy and resource mobilization infrastructure encompassing the global, national, and subnational (in large federated countries) contexts
   • Interagency coordination committee use at regional and national levels, first used in the Americas/Pan American Health Organization for their regional polio eradication initiative during 1985-1991
   • Extensive infrastructure and experience for conducting partner coordination of resource mobilization and advocacy, policy and strategy development, management and oversight, planning, communications and community engagement, and implementation and service delivery
   • Methods and infrastructure for tracking financial resource requirements and cash flow management."
8. "Strategic Planning and Policy Development" - This has included: multiyear strategic plans and planning processes throughout the life of the GPEI; elaborated national emergency action plans for the 3 remaining polio-endemic countries (Afghanistan, Nigeria, and Pakistan); technical advisory groups (TAGs) and policy development at the global (Strategic Advisory Group of Experts on Immunization - SAGE), regional, and national levels in key countries; and national, state, and subnational task forces in key countries.
9. "Oversight and Independent Monitoring and Evaluation" - "The GPEI has learned the fundamental need for a strong oversight framework to support the program, monitoring, and management of the collaborative process and for communicating with and sustaining the commitments of a diverse group of stakeholders."
10. "Monitoring of Program Accountability and Performance" - "...In large, federated countries with weak health systems, it became necessary to engage political leaders at the subnational level and put in place systems for greater staff and financial accountability..."

"We have the opportunity and obligation to build a better future by applying the lessons learned from the GPEI and its infrastructure and unique functions to other global health priorities and initiatives. Chief among these prospects is the opportunity to strengthen overall immunization programs, especially routine immunization systems, in low-income countries, including India, through the use and redirection of GPEI resources and innovative approaches that have been outlined in this article."