Lessons Learned from the CORE Group Polio Project and Their Relevance for Other Global Health Priorities

"These strategies have the potential for contributing to the reduction of child and maternal mortality in hard-to-reach, underserved populations around the world."

Over a period of 2 decades, the CORE Group Polio Project (CGPP) has coordinated the engagement of non-governmental organisations (NGOs) in hard-to-reach and resistant communities in 11 countries where polio transmission has persisted. As the world transitions toward global polio eradication, what lessons can be gleaned from the community-focused polio eradication strategies implemented by the CGPP, and how might they be applied to other global health priorities? This final article within a series of articles detailing the work of the United States Agency for International Development (USAID)-funded CGPP (accessible through Related Summaries, below) addresses these questions.

The article reviews CGPP strategies explored in depth in the earlier series articles, including pursuit of the missed child, microplanning, independent campaign monitoring, use of community health volunteers and community mobilisers, community-based surveillance, targeting of geographic areas at high risk, the secretariat model for NGO collaboration, cross-border collaboration, registration of vital events, and development of the capacity to respond to other health needs.

"Many of the lessons learned from the CGPP arose from the CGPP's work with very specific population groups, namely, those who have been chronically unreached, marginalized, and highly vulnerable. Experience has shown that these populations are likely to push back against top-down vertical programs that focus on narrow disease-specific priorities unless efforts are made to recognize these people as a valued resource whose own needs and priorities for improved health are also addressed."

The Global Polio Eradication Initiative (GPEI) has identified characteristics and innovations developed to build social support for vaccination; as the authors of this article argue, the CGPP played a key role in developing all of the following elements for reaching underserved populations:

1. Identification and pursuit of the missed child (and newborn)
2. Identification of individuals, themes, and social pillars that can unify and motivate diverse population groups for a common goal
3. Mobilisation of communities through house-by-house contact on a large scale, not only for polio immunisation but also for discrete health interventions such as vitamin A supplementation
4. Creation of detailed local neighbourhood vaccination team microplans and maps, along with identification of locally influential people to assist in addressing those who are hesitant or resistant to immunisation
5. Collection and analysis of social data at the most-local level to understand and engage effectively with the local population
6. Tracking of mobile and migrant groups and communicating with these groups while they are in transit
7. Engagement with groups while they are away from home during campaign days, such as with those attending social, cultural, or religious events
8. Use of traditional, religious, community, and civil society leaders and structures for community mobilisation
9. Improvement of interpersonal skills, management, and motivation of frontline health workers
10. Development of evidence-based approaches to guide social mobilisation and community engagement through ongoing, rigorous monitoring and evaluation
11. Capacity to respond to community demands for additional services beyond polio immunisation
12. Engagement of communities and local civil society through other structures in addition to ministries of health
13. Mobilisation of the international, national, local NGOs, and communities in high-risk areas to reach every child with polio immunisation

Specific lessons learned include the following:

• The social mobilisation network (SMNet) "is a powerful tool for achieving public health priorities" - In India, SMNET contributed to a decline in refusals in both Bihar and Uttar Pradesh to less than 1% of households. Furthermore, full routine immunisation coverage in areas defined by the GPEI as being at high risk for polio transmission in Uttar Pradesh increased from 36% in 2009 to 81% in 2016 and in Bihar from 54% in 2009 to 89% in 2016.
• Cross-border initiatives are needed to control transmission of infectious diseases - CGPP's meetings and committees established relationships between health workers on both sides of international borders, and the links developed with community members such as barbers helped alert health workers to newly arrived mobile and nomadic populations, thereby improving microplans and acceptance of immunisation.
• Community-based surveillance can be a useful complement to facility-based surveillance in hard-to-reach populations - This system provided a useful alternative in South Sudan when many of the formal health facilities were destroyed, closed, or became dysfunctional due to conflict, as described in another article in this series. In 2018, the CGPP adopted community-based surveillance to support disease surveillance for the Global Health Security Agenda, targeting a larger number of primarily zoonotic diseases in Kenya and Ethiopia.
• Independent campaign monitoring (ICM) "is essential for priority public health programs" - Before the introduction of ICM, campaign coverage and quality were measured using often-unreliable "administrative data" (data obtained from reports of health workers regarding the number of doses given). ICM has been able to offer "a much more accurate sense of the campaign quality and of the amount of improvement required to achieve interruption of transmission of wild poliovirus. The accuracy of the data provided by ICM contributed to the initial interruption of wild poliovirus transmission in 2001."
• The CGPP secretariat model "is an effective way of mobilizing NGOs and civil society" - Although NGO health projects often have significant community-level impact in limited geographical areas, their efforts are not conducive to the achievement of large-scale global initiative. The CGPP's secretariat model of NGO partners has been "a powerful and effective mechanism for engaging communities in polio eradication activities. It has also been a highly efficient and effective way for international donors to channel financial support for programming that will reach vulnerable and hard-to-reach populations." The secretariat model was used by USAID in 2007 to support global efforts to prepare for pandemic influenza.
• NGOs can complement what governments provide to address health priorities - Maintaining the NGO network that has been established and, perhaps, even expanding it more broadly could be a key resource for health improvement generally but also specifically for surveillance and global health security.
• "Relentless pursuit of the missed child (or of children in need of essential services) is necessary for child health programs to achieve optimal results" - "This requires identifying who these children are and mobilizing communities to help ensure that essential services reach these children."
• Local registration of vital events and child registries is feasible and useful.
• Promotion of services in the home is necessary in part to identify children who are in need of essential services, provide referral, look for outbreaks of infectious diseases, and register vital events (births and deaths).
• "Provision of a broader set of basic and essential services that respond to community-felt needs helps secure buy-in from local communities for disease-control activities (such as polio eradication) that are not community priorities."

To which global health priorities could the CGPP experience contribute? For example, applying the CGPP approach of using community-level workers to visit homes on a regular basis would make it possible to address the leading local causes of maternal, perinatal, neonatal, and child deaths through the implementation of evidence-based interventions. Broadly, CGPP points to the potential of engaging the community, strengthening community platforms, and promoting community ownership in meeting global health goals in difficult-to-reach and vulnerable populations around the world.

In conclusion, the authors suggest that "transitioning the target from polio eradication to ending preventable child and maternal deaths and continuing to use the NGO networks for community-based surveillance for identifying and responding to disease outbreaks and for responding to emergencies would be a readily achievable shift because the strengths of the CGPP could be applied and the results measured."

Specifically, NGO networks have the potential to contribute to decreasing child and maternal mortality rates through:

• Support for community-level workers, who can promote healthy household behaviours and health facility utilisation when warning signs develop;
• Support for the existing CGPP community-based systems and their coordination with health facilities to promote outreach vaccination and to identify cases of vaccine-preventable diseases;
• Continuation of close coordination between the CGPP community-based systems and the formal health services system;
• Support for and strengthening of existing community health worker (CHW) programmes with lessons learned from the CGPP, including CHW-led behaviour changes using interpersonal communication, consistent and repeated contact, and modeling of positive behaviours;
• Application of these successful community-based methods of engagement in underserved and high-risk urban/periurban populations; and
• Continuation and expansion of the secretariat model to coordinate NGO collaboration.

Through these activities, it could be feasible to expand the approach to achieve broader public health benefits beyond polio by:

• Fostering the capacity of communities to take ownership of their health problems by helping them understand what the levels of mortality of mothers and children are in their community, the degree to which mortality has been declining (or not), and how they can contribute to further reductions in mortality;
• Monitoring vital events (deaths as well as births) through systems of community collaboration; and
• Introducing verbal autopsies through community collaborations to help communities understand who is dying of what and actions that could be undertaken by the community to prevent similar deaths in the future.