A Multi-Pronged Scoping Review Approach to Understanding the Evolving Implementation of the Smallpox and Polio Eradication Programs: What Can Other Global Health Initiatives Learn?

"[G]lobal health programs can continue to learn from each other's implementation experiences more effectively when this experience is captured and made available in user-friendly formats."

Two global eradication efforts, the Smallpox Eradication Program (SEP), which was launched in 1959, and the Global Polio Eradication Initiative (GPEI), which was launched in 1988, offer lessons on implementation strategies for addressing factors to global eradication and other global health initiatives. Drawing on the interdisciplinary field of implementation science, the review was conducted as part of the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) consortium, which was convened by The Johns Hopkins School of Public Health with partners from 7 selected countries. (See Related Summaries, below.)

After summarising the history of the establishment of SEP and GPEI, the article outlines the conceptual framework and search strategy. Two hundred articles were included in the SEP scoping review, 1,885 articles in the GPEI scoping review, and 963 documents in the global- and country-level grey literature review.

Linkages of SEP experience to the GPEI and lessons from these examples include:

• Planning and resource mobilisation: Although SEP experience led to the recognition of the value of blueprints, the GPEI did not show high fidelity in implementing these lessons. For example, in India, while a national blueprint (based on global guidelines and South East Asia Regional Office (SEARO) negotiations) had been established for polio eradication, inadequate resources were provided to implement the blueprint. Unlike under the SEP, the protracted time period under which the GPEI has been active means that different planning strategies have had to be rapidly deployed - sometimes successfully, according to the literature. For example, the swift, synchronised global switch from trivalent oral polio vaccine (OPV) to bivalent OPV was attributed to several factors, including the coordination work of the Immunization Monitoring Board, high-level engagement and advocacy, and proactive communication with clearly defined dissemination channels.
• Management and problem-solving: The SEP's development of robust record systems was a key learning carried forward into the GPEI. Actors involved in polio eradication developed new approaches to the kind of records that were kept, including community mapping and micro-planning, and strategies to mark houses for programme monitoring. These strategies were reportedly particularly important for improving coverage among hard-to-reach communities. For example, the CORE Group utilised localised planning and social mobilisation activities in Uttar Pradesh, India in order to improve supplemental immunisation and worked to capture record keeping systems that could help them track the impact of these interventions.
• Monitoring and evaluation (M&E): Having specific mechanisms for feedback to relevant stakeholders in order to modify and evaluate programming was a common strategy used by the SEP. Likewise, from its earliest days, the GPEI has emphasised involving stakeholders representing different areas of expertise to allow for independent monitoring and oversight and to maintain transparency and accountability. For example, the introduction of checklists for frontline workers, along with supportive supervision to enable checks on data accuracy, helped reach missing key child populations.
• Engagement and capacity building: Involving stakeholders, such as communities, in the implementation effort was the most common strategy identified in the SEP literature under this theme. GPEI innovated in this area, including by strategically engaging youth, establishing national-level committees for traditional and religious leaders, and setting up presidential-level committees and strategic partnerships for national and international oversight of GPEI implemenation. For example, in countries in the South-East Asia region, stakeholder engagement events were held in each of the 11 countries that would be making the switch from trivalent to bivalent OPV; these stakeholders then remained involved through testing of implementation dashboards, M&E plans, and roll-out of the switch. One evaluation cited here highlighted the fact that deconstructing the mechanisms of rejection of polio immunisation required the GPEI to work with traditional and local government leadership to systematically identify non-compliant households, block rejection areas, and identify and address the most salient concerns.
• Communications and mass media: Increasing awareness among intended populations was a common strategy in the SEP and has remained critical within the GPEI, particularly for reaching marginalised populations. As a GPEI partner, the Rotary International's PolioPlus Program demonstrated the importance of civil society partnerships in global health and international advocacy. Rotary's polio eradication efforts featured coordinated campaigns and awareness-raising using communication methods and celebrity engagement at global and national levels. The country-level grey literature also frequently mentions the importance of raising awareness, including awareness of polio activities, benefits of immunisation, or sharing information to address concerns that can result in vaccine hesitancy. "Global health programs going forward can integrate this experience by planning for the most effective role for communications, particular[ly] as the use of mobile devices and connectivity continues to expand around the world."

Reflecting on these findings, the researchers cull out some lessons for other global health programmes, such as the importance of integrating stakeholder engagement across all aspects of programme implementation - from planning through to evaluation - and of considering which level(s) are most appropriate for specific programmes and contexts.

The researchers suggest: "Linear learning did not always occur between SEP and GPEI; several lessons were lost and had to be re-learned. Implementation and adaptation of strategies in global health programs should be well codified, including information on the contextual, time and stakeholders' issues that elicit adaptations. Such description can improve the systematic translation of knowledge, and gains in efficiency and effectiveness of future global health programs." To that end, the STRIPE project plans to develop resources and a curriculum for teaching implementation science and opportunities for other global health programmes to learn from the SEP and GPEI implementation experience. It is expected that this core curriculum will be adapted and implemented across diverse country contexts, as well as presented as a massive open online course (MOOC).