Preventing Importation of Poliovirus in the Horn of Africa: The Success of the Cross-Border Health Initiative in Kenya and Somalia

"The CGPP has demonstrated the value of an institutionalized approach that is collaborative and coordinated. This important strategy is adaptable to address other communicable diseases that transcend borders..."

In the aftermath of an outbreak of wild poliovirus (WPV) in the Horn of Africa (HOA), in 2014, Kenya's Ministry of Health (MOH) requested that the CORE Group Polio Project (CGPP) Kenya and Somalia HOA Secretariat initiate polio eradication activities in 5 counties along the Kenya-Somalia border. This article, which is part of a series of articles detailing the work of the United States Agency for International Development (USAID)-funded CGPP (accessible through Related Summaries, below), describes a systematic approach to institutionalising processes of dialogue and facilitation that can provide for a sustainable and effective joint cross-border health platform. It examines an operational model called the Cross-Border Health Initiative (CBHI) to support joint intercountry collaboration and coordination efforts.

The authors provide context: Kenya, Somalia, Ethiopia, South Sudan, and other HOA countries share a range of complex factors that enabled the 2013 WPV outbreak, including porous and sparsely populated borders, insecurity due to armed conflicts, and weak health systems with persistently under-resourced health facilities, resulting in low-quality care and low levels of immunisation coverage in mobile populations. Assessing and addressing persistent communication gaps at the subnational levels was necessary to gain traction for improved immunisation coverage and surveillance activities.

Under the leadership of the respective MOHs of Kenya and Somalia and in collaboration with the World Health Organization (WHO), the CGPP began holding cross-border meetings in October 2014 with the objective of improving collaboration between the health and administrative authorities of border regions. In October 2015, the CGPP established a total of 7 CBHI committees in 5 polio high-risk counties in Kenya and 2 regions of Somalia. They were tasked with ensuring the vaccination of all cross-border populations, supporting the detection of cases of acute flaccid paralysis (AFP), conducting joint case investigations of transborder AFP and WPV cases, and synchronising all polio supplemental immunisation activities (SIAs).

To guide the CBHI committee members, the CGPP Secretariat in coordination with the MOH wrote a terms-of-reference document to structure regular meetings and outline roles for reporting and for the implementation of action plans. The project trained and provided the committees with selection criteria for recruiting community health volunteers (CHVs) to conduct social mobilisation, perform community-based surveillance on vaccine-preventable diseases, report suspected AFP cases, promote routine immunisations, and track immunisation defaulters. In turn, the committees provided training materials for border health facility staff and border CHVs, including reporting forms to identify key diseases.

The data the authors examined reveal that a key success of the CHBI committees' work has been the recruitment and training of CHVs, who reported all suspected AFP cases from conflict-prone and insecure areas inaccessible to trained health workers. Table 2 in the paper shows the number of AFP suspected cases reported by the CHVs over the 3-year period, "highlighting the role of the community as an excellent resource to support AFP surveillance for the polio eradication program."

The authors find that the CBHI "has improved information sharing between countries on polio eradication by identifying and addressing surveillance and immunity gaps in high-risk mobile populations, and by developing micro-plans along the borders to synchronize SIAs along the borders." Table 4 shows that the CBHI mapped 328 crossing points and 1,105 cross-border villages, helping ensure an increased number of children vaccinated during the SIAs in the border areas between 2016 and 2018.

Furthermore, Table 5 provides a tally of the number of health staff who were trained in polio eradication and the number of health staff who received supportive supervision. "These are both well-established and proven capacity-building interventions for improving performance", including in the areas of advocacy and social mobilisation. Along these lines, the government Expanded Programme on Immunization (EPI) and surveillance officers carry out their activities through direct, personal contact on a regular basis to guide, support, and assist designated healthcare facility staff to become more competent in their immunisation and disease surveillance services.

Among the operational challenges faced by the project: the high cost of programming due to the difficult terrain (poor roads and insecurity) and the occasional border closures hampering the cross-border work. Some of these challenges were overcome by working closely with community leaders, building the capacity of the community through the CHVs to conduct the cross-border work, integrating the polio interventions with other cross-border activities undertaken by non-governmental organisations (NGOs), and leveraging their presence and expertise. These partnerships created synergy and reduced the cost of programming.

The authors outline contributing factors that account for the early successes of the CBHI:

1. The communities that straddle the border of Kenya and Somalia share a common language and culture, allowing for easier collaboration.
2. "The contribution of communities through participation in the cross-border health committees and the community-based surveillance by CHVs has magnified the CGPP's credibility and ownership among border communities."
3. "The cross-border forums have heightened sensitization and advocacy for cross-border issues, leading to high-level political commitment and support from the respective government health authorities and renewed interest and support from the United Nations partners."
4. "Frequent cross-border committee meetings (monthly, quarterly, and annually) have improved opportunities for communication, stronger partnerships, joint regional advocacy, effective management of challenges, and the facilitation and implementation of collective outbreak response activities."
5. Cross-border meetings have provided a local-level forum to exchange information and carry out synchronised action for health service activities.
6. "Effective communication among the cross-border committees and border authorities, coordinated immunization activities, and sharing of AFP surveillance data have led to an improved, in-depth understanding of the dynamics of cross-border threats of WPV importations."
7. "The diverse committee representation of the stakeholders has ensured wide sharing of information across the borders..."
8. "Implementation of the CBHI in Kenya and Somalia has strengthened information flow through monitoring and evaluation of joint action plans."
9. The border health facilities have conducted mapping and profiling of cross-border populations for routine immunisation and SIA micro-planning in hard-to-reach border villages and in high-risk populations.
10. The capacity built through these committees, although specific to polio eradication, can serve other health initiatives.

The CBHI is now part of the operational health plans of border health units and the annual work plans of the participating county departments of health, hopefully ensuring sustainability of the CBHI after the end of the project. This knowledge has been captured in the CBHI Operational Guide, which is available as an online supplement to this article.

The authors conclude that the CBHI has been effective in bolstering immunisation coverage, disease surveillance, and rapid outbreak response in border areas. They stress that "Effective, robust cross-border coordination of polio eradication activities requires a high level of political commitment, solid coordination, and mobilization of cross-border communities and their leaders."