Pakistan’s polio conundrum, only reforms can help

Despite exemplary civil-military leadership, government ownership, unprecedented sacrifices, a viable health system, and hundreds of vaccination campaigns, why should Pakistan still be in this situation? It’s a million-dollar question.

Pakistan Polio

Saving our children from the menace of Polio is not only a public health gain but also a boost to the national economy, productivity, and societal well-being. Pakistan has remained an integral part of the eradication efforts since its launch in the year 1988 with help of the Polio Program. Despite successive regime changes, economic and security challenges, Pakistan has done everything possible to attain the goal of a polio-free Pakistan. Nonetheless, we have not yet reached the zenith of our efforts – only second to Afghanistan.

Surprisingly, we fared poorly in this race even than Afghanistan – 81 cases in Pakistan against 53 in Afghanistan. We also struggle with vaccine-derived strains of P2 Virus, so far 83 children have been inflicted, this number was 22 in 2019.

The recipe for success is simple: Reform, restructure and reboot.

Despite exemplary civil-military leadership, government ownership, unprecedented sacrifices, a viable health system, and hundreds of vaccination campaigns, why should Pakistan still be in this situation? It’s a million-dollar question.

Read more: Poliovirus Eradication: An uphill battle for Pakistan

Independent Monitoring Board to the rescue

Thankfully, the conundrum was resolved by the IMB (Independent Monitoring Board)- the apex monitoring body for the Polio program. It has warned the program consistently for urgent course corrections but particularly this last report of July 2020 expressed it in clearer words.

IMB report skeptical about the effectiveness of Polio Program

The report dissected the real reasons behind the programmatic collapse and provided concrete recommendations, although some were a repeat of previous reports. The report, while lamenting the Polio cases surge, has questioned the capacity and strategic depth of the program and mentions “ Cases of poliovirus had increased fivefold between 2018 and 2019. There was uncertainty and doubt surrounding the effectiveness of strategies and tools.”

IMB much to the anguish of GPEI (Global Polio Eradication Initiative), – a partnership of WHO, UNICEF, Bill & Melinda Gates Foundation, CDC Atlanta, and Rotary international-, had the audacity to clearly pinpoint the real reason for this grotesque situation.

Global Polio Eradication Initiative under interrogation

The report questioned the governance, management, architecture, and poor accountability of GPEI run resource-intensive program in Pakistan, at page 5 of the report, it says “Donor countries made an unprecedented demand that the GPEI should review and reform its governance and accountability structures. This did not reflect a reduced determination by these donors to get the job done, but rather the depth of their concern that there was no clear end in sight for polio eradication, and a lack of clear accountability in a $1 billion a year spending program.” The report assertively questions the lack of accountability and governance of the program and says, “The IMB has constantly been struck by the lack of clarity in many of these aspects of accountability, governance and strategy formulation within the GPEI”.

Further expressing its frustration with GPEI capacity, the report says, “More broadly, the IMB feels that the GPEI is not yet on top of the complexities of communicating in relation to the type 2 vaccine-derived poliovirus challenge.”

IMB offers to help and provide a more adaptable structure for the program

The report inserts the comments of POB (Program Oversight Board, a high-level Donors Forum) that is equally frustrated with poor management, high cost, and lack of transparency in the polio program, on Page 19 of the report it narrates, “{We] encourage the program to consider its structure and governance as we enter a new phase, with different risks and additional challenges to eradication. We would welcome a review of the current governance arrangements, with the objective of ensuring we have an adaptive, politically engaged and community-focused, objectively scrutinised, lesson-learning structure that can adjust to emerging challenges. Many of the issues raised in the GPEI’s 2019/2020 internal review of governance are similar to those found in the review prompted by the IMB recommendation in 2013. The weakness of accountability mechanisms in the Global Polio Program is a very serious matter.”

Donor countries also frustrated at GPEI

It further says, “… It is understandable that the donor countries are deeply frustrated by this situation, and so raised their concerns in a very forceful way at the Polio Oversight Board. What it boils down to is that they are paying the GPEI to achieve immunity levels to poliovirus sufficient to stop transmission of the virus globally. The GPEI is not delivering on its side of the bargain.”

Despite successive regime changes, economic and security challenges, Pakistan has done everything possible to attain the goal of a polio-free Pakistan.

Regarding the fund’s management and transparency that the bilateral, multilateral donors, philanthropies pumps into this partnership the report states, “ ….the case that polio dollars are safe in GPEI hands will, in future, need to be more convincingly made to the governments and taxpayers of these countries”

Polio Program not able to reach its full potential due to leadership vacuum

Besides Polio vaccination, the Polio program has a large space to provide impetus to other health interventions as well but due to leadership vacuum it has not been able to tap that “ low hanging fruit”. This shortcoming has been consistently flagged by IMB in its consecutive reports but to no heed. In its previous report of November 2019, the IMB had highlighted the urgent need to move from a vertical mode of the program to an integrated but wasn’t heeded as highlighted in that report “…that a purist vertical program, based on heavy persuasion, can no longer work everywhere.”

Read more: Tale of two emergencies: Polio and Covid-19 through IMB lens (Part 1)

Polio program must adapt to different circumstances, IMB urges

IMB was also found skeptical of the GPEI capacity and will for implementation and execution of the recommendations provided to it and it sates “So, despite the recommendations made on water, sanitation, hygiene, and basic health services in both the 16th and 17th IMB reports, action to address this critical gap has been very limited”. it adds, “The Polio Program must adapt to different circumstances; actions should include strengthening and participating in essential immunisation, multi-antigen campaigns and birth dose”.

the Government at the highest level have been kept in the dark and if at all there is an effort to fill this vacuum, it is thwarted through Machiavellian tactics.

The program likely to go on funding shortfall in 2021

The program is likely to face a funding shortfall due to operational and management lacunas and IMB has sensitised the world at large regarding an impending fund shortfall where it has predicted a funding gap for the year 2021 between $234 million and $890 million. Enough of a wake-up call for the program to reshape and reform its systems, management, and operations.

Polio Program good at making excuses and too forgiving of itself

The program has developed a ritual to engineer reasons for its failure and address various audiences the way they would like to. This fact has been picked by IMB and on page 48 of the report it warns, “ That vision currently seems a distant pinpoint of light. The Polio Program is in dire straits… the “almost there” narrative was believed by too many people. The phrase now being used to encourage everyone is: “The last mile is always the most difficult”. The Polio Program is too forgiving of itself.”

Read more: Tale of two emergencies: Polio and Covid-19 through IMB lens (Part 2)

Half-Baked efforts

Another reason for the program failure is half baked efforts to change community perceptions, attitude, and acceptance, regarding the progress in this domain, the report says on Page 51, “ Throughout its lifetime, the IMB has sought to encourage the Polio Program to use local knowledge and insights as well as communities’ deeper interests to shape its work. It has strongly advocated creativity and innovative use of data to solve problems. Such a programmatic culture has been agonisingly slow to take roots”

Leadership Vacuum to be taken seriously

The key issue in the program is the inspiring leadership vacuum, which has not been taken seriously. To fill this urgently, IMB warns on Page 53, “ The Pakistan Government’s national polio leadership structure no longer contains a national Polio Focal Person, as it has in the past.… and appoint a new national Polio Focal Person” But since this arrangement may challenge some personal agendas, the Government at the highest level have been kept in the dark and if at all there is an effort to fill this vacuum, it is thwarted through Machiavellian tactics.

Numerous advisory bodies offered to help make it through this last mile

Apart from IMB, numerous technical, advisory bodies and professionals have been consistently advising the Polio program for structural, institutional, and “fit for purpose Reforms” that can ensure visible government leadership, realign strategies and integrate other health priorities like Nutrition, WASH, EPI and MNCH in its design and scope. Government-led institutional, governance and management reforms are the best way forward.

Saving our children from the menace of Polio is not only a public health gain but also a boost to the national economy, productivity, and societal well-being.

Recipe for success

The recipe for success is simple: Reform, restructure and reboot. The program should move from complexity to simplification, from verticality to integration, from quantity to quality, and from numbers to goal. It’s all about possibilities’ and no rocket science is required, only some bold actions, innovative strategies, few quality vaccination campaigns alongside a robust routine immunisation system would finish the job and quick too.

Its high time that government at the top takes serious note of the situation, commission an independent assessment, establish a “Neutral technical working group”, assign visionary leadership, enact across the board accountability and give a deadline for the whole business wrap-up, this way Polio can be eradicated in months.

Safe to say that we might continue holding campaigns after campaigns with the same results, how many more and at what cost no one is sure? The cause is worth the effort and focus.

Dr. Nadeem Jan (Tamgha I Imtiaz) is the most decorated health & polio expert, who has an illustrious career with UN, USAID, World Bank, Gates Foundation and Governments of Pakistan, Somalia,Kenya, South Sudan, Afghanistan and Philippines. He can be reached at Nadeemjan77@hotmail.com.

Read more:Pakistan and Afghanistan: last battlegrounds of Polio eradication


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