Key Considerations: Localisation of Polio Vaccination Efforts in the Newly Merged Districts (Tribal Areas) of Pakistan

"In this environment, it is essential that vaccination programmes localise - by taking careful account of the local context, improving local ownership of the programmes, understanding and mitigating the issues at a grassroots level, and tailoring efforts to achieve polio eradication goals."

Polio remains endemic in Pakistan, where many stakeholders continue to have low confidence in frontline workers and polio vaccination campaigns. This brief reviews the social, cultural, and contextual considerations relevant to increasing polio vaccine uptake amongst vulnerable groups in Pakistan's tribal areas. It focuses on the current country context, in the aftermath of the 2018 merger of the former Federally Administered Tribal Areas (FATA) into Khyber Pakhtunkhwa province. Drawing on evidence from academic and grey literature, data on polio vaccine uptake, consultations with partners working on polio eradication in Pakistan, and the authors' own programme implementation experience in the country, the brief is part of a series authored by participants from the Social Science in Humanitarian Action Platform (SSHAP) Fellowship.

As the authors explain, Pashtun tribal areas of Pakistan face prolonged and ongoing insecurity and governance issues, and people in these regions have faced long-standing political, social, and economic marginalisation. The 2018 renaming of FATA (now: Newly Merged Tribal Districts) and incorporation into KPK mean that Pakistan's federal constitution and governance structures now apply to the region. FATA integration has been controversial; tribal elders and some political parties have opposed it, with some elders lamenting the loss of their tribal dignity and the Jirga system, which is considered a trusted way of solving local disputes among the Pashtun. Similarly to how the government is not trusted to resolve local disputes, polio staff are also often less trusted by Pashtun communities to "resolve" the "problem" of polio.

Furthermore, after the Taliban takeover of Afghanistan, tribal people in both Pakistan and neighbouring Afghanistan have been more likely to resist polio vaccination. Previously, many opposed vaccination efforts for political and social reasons, and this opposition has been emboldened due to the political and cultural alignments between some tribal groups in Pakistan and the ruling Taliban in Afghanistan. Given the geographic and cultural integration across the border, rumours and conspiracy theories about vaccination in Afghanistan influence polio eradication efforts in Pakistan as well. Authorities have also warned that the large number of Afghan refugees coming to Pakistan may present a new challenge to polio eradication efforts in the tribal areas.

The Pakistan Polio Eradication Programme, which started in 1994, has been marked by complex challenges. For example, for decades, various tribes have complained that members of the ruling party excluded them from positions with the programme, while recruiting the politicians' "own people" as workers. Members of some tribes will not allow their children to be vaccinated by workers from other tribes, particularly those of their political rivals. The authors detail many of the other reasons given by caregivers for refusing the oral polio vaccine (OPV), including perceived side effects, beliefs that healthcare workers are not vaccinating their own children, concern about dangerous and haram (i.e., prohibited by Islam) ingredients, worries about adverse effects in terms of infertility or puberty, and questions over why ancestors never got vaccinated. Security concerns also drive vaccine refusal in the region; frontline workers feel reluctant to participate in immunisation campaigns due to threats to their lives.

Furthermore, polio eradication efforts are often a "battleground" for wider political issues. Tribal communities have engaged in tactical boycotts of polio campaigns on a mass level to mobilise around demands for electricity, roads and infrastructure, basic health facilities, distribution of free food items, mosquito nets, and removal of police charges against tribesmen. In March 2021, more than 6,000 caregivers refused polio vaccination from Tirah Bazar, Tribal District, Khyber. They requested a main road into the Sarsobay area, which is blocked by the army and has made transport and access to communities more difficult. The issue still needs to be resolved and as such, the number of refusals grows with every polio immunisation campaign.

There are also social, gender, and cultural barriers to polio vaccination in these tribal areas, which have been male dominated for centuries. Tribal women are often not permitted to get an education or make decisions about who they marry, when they have children, or whether to vaccinate their children. Female vaccinators are an integral part of polio campaigns, but tribal culture does not allow women to work outside their houses. It is impossible to vaccinate children of a house without any female staff, as the tribal culture does not allow men to knock on the door if the male member of the house is not at home.

Some Muslim clerics in the region justify this approach through teachings in the Quran; in general, the rich historic culture of the tribal region is insular. It has been observed during field visits that many of the male caregivers have been influenced by local religious leaders who announce during formal religious gatherings or funeral ceremonies that if people vaccinate their children, then they should not contact them for further religious activities. "Religious leaders' influence and opinions (which tribal people strongly comply with) always affect the vaccination campaigns negatively."

Beyond the various political, social, religious, and cultural issues discussed, there are a variety of other practical barriers to vaccination, such as fake finger marking (the marking of a child's finger to avoid polio vaccination).

However, vaccine resistance is being addressed successfully in some settled areas through innovative approaches tailored to the community context. These include deploying evening vaccination teams, holding health camps, tracking missed and unavailable children, addressing refusals before the campaign starts, and engaging pro-vaccination influencers. For example, civil society, local influencers, celebrities, religious leaders, and frontline workers were involved in the polio vaccination campaign in December 2021, and evidence from the authors' experience indicates that the participation of these trusted local stakeholders encouraged community acceptance of the vaccine and should continue to be fostered in the future.

Without consideration of the specific tribal area context, the programme will likely continue to fall short of key polio eradication goals, as argued here. Some recommendations for facilitating this consideration include:

• Conduct a rapid ethnographic assessment to understand the post-2018 political-economic context, tribal systems and power dynamics, and the key stakeholders to involve in polio eradication efforts, and to collect information on major gaps in the efforts.
• Consider ways to adapt polio eradication efforts to local contexts, particularly given the new political context, to improve local ownership of the programme. This could include improving social mobilisation at a local level (e.g., to raise awarness of the importance of vaccination), fostering long-term engagement with local influencers, and identifying and linking up with other health and social programmes to better integrate polio eradication and build trust with communities. It may be necessary to work with the local Jirga system and local leadership.
• Involve local-level religious leaders like imams and notable clerics, as well as tribal elders and maliks (elected elders). People are influenced by such figures because of their dominant position and strong influence on tribal society. They can be enlisted to deliver important messages during religious events and congregational prayers.
• Conduct research in targeted locations where there are more vaccine refusals and higher numbers of confirmed cases to analyse preferred communication channels for people to receive information (e.g., social media, electronic/print media, house-to-house outreach, mass awareness campaigns, radio, theatre, and other channels).
• Whom people trust varies at a granular level; therefore local-level influencers can be used to reach people in locations where there are more refusals or a higher number of cases.
• Continue robust monitoring and surveillance for fake finger marking - bearing in mind that this should be addressed in a sensitive way during campaigns in tribal areas.
• Increase human resources and rely on permanent staff instead of hiring casual workers during campaigns. Permanent staff are more experienced and have vital technical skills, whereas new casual workers need training; this can lead to high staff turnover. Recruit vaccination staff locally from the tribal areas; these workers are familiar with the context and are more accepted by the community. Where possible, recruit female workers.
• Provide sufficient resources and logistics support, such as transportation, training, protective equipment, refreshments, Information, Education & Communication (IEC) materials in Pashto, and additional incentives and expense reimbursement during campaigns to increase field staff motivation and reduce staff turnover.