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Thursday, May 23, 2024

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

Pakistan's polio program has always been too protective and defensive regarding its performance. When a target is missed each year it engineers various reasons for the results rather than reflecting back in all honesty, digging out reasons, holding own self accountable and taking drastic remedial actions it always find reasons in the external environment.

In the same report, the IMB made a recommendation for a GPEI governance review in order to make it more robust, transparent, efficient and cost effective. polio

The report insert the comments of POB (Program oversight Board) which is equally annoyed with the poor management, high cost and lack of transparency in polio program, on Page 19 it is described, “ At the Polio Oversight Board held in November 2019, the polio donor countries made a statement that inter alia said:

[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 scrutinized, lesson-learning structure that can adjust to emerging challenges.

Read More: How can Pakistan deal with rising polio cases?

Issues raised in the GPEI’s 2019/2020 internal review

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. Some of the eight recommendations are works in progress since further reviews and planning activities will develop them further.” The weakness of accountability mechanisms in the global Polio Program is a very serious matter.

“The latest governance review does not, and cannot easily, remedy these weaknesses. 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.” The Polio Program suffers the disadvantage of many partnership-based global health programs of not having a straightforward answer to the question: “Can you please tell me who is in charge?”

Read More: Will Prime Minister Imran Khan be able to eradicate polio from Pakistan?

Regarding the decision by the program to abolish the CBVs (Community based Vaccinators) it says On page 26 ,” The IMB is concerned about the scaling down of the Community Based Volunteer program in Pakistan. This was a key transformation that the Pakistan Polio Program felt had brought them to the brink of eradication.”

It adds on Page 28 regarding reasons of CBVs failure where program management at national and provincial level has been cited the main reason for the slow down in performance of the CBVs network, “ It certainly lacked authoritative oversight and performance management from the national level.”

The IMB believes that the decision to scale down should be kept under careful review. The Polio program in Pakistan should pay very close attention to the risks of performance failure in areas that are switching from community based volunteers to special mobile teams”.

Polio program in Pakistan

Pakistan’s polio program has always been too protective and defensive regarding its performance, when a target is missed each year it engineers various reasons for the results rather than reflecting back in all honesty, digging out reasons, holding own self accountable and taking drastic remedial actions it always find reasons in the external environment.

Regarding GPEI poor performance and its defensive mechanism the report on page 48 ,it says, “That vision currently  seems   a  distant  pinpoint of light.

The Polio Program is in dire straits. With a worsening epidemiological position, during 2019, for both wild and vaccine-derived poliovirus cases,  the world was  hit by a devastating pandemic of coronavirus. A yawning funding gap is opening.

Read More: Who killed two polio workers in Swabi?

The  Polio Program   stands  in  the  middle of2020  confronted by twin challenges that stand in the way of eradication. The first is the challenge of  facing  up  to  the  real  reasons   that  it  went off track  in 2019  into a  jaw-dropping  slump  of performance  at  a  time  that  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.” “

The program has been run on vertical lines for more than 3 decades now and despite various alerts from many technical brains to integrate this in the larger health or emergency architecture it has chosen the solo flight for reasons best known to the “lords of Polio”.

All in-country Polio programs should be designed to work with other teams

IMB has also been consistently flagging this in various reports and in this particular report regarding the need for moving from the vertical nature of the program in to integrated,  the report on Page 58 says, “All in-country Polio programs  should  be  designed  to  work  with  other  teams  to  deliver vaccination for polio as part of other essential services  (especially Immunization); the precise model of integration should be tailored to match local circumstances and community preferences; programs  should also seek  to meet  communities’ wider and basic  needs  (related  to water, sanitation, soap or other amenities that communities value.”

The Polio Program must adapt to different circumstances; actions should include strengthening and participating in essential Immunization, multi-antigen campaigns and birth dose.”

Read More: Polio cases take Pakistan by storm, urging immediate action

While the report demystified some of the fallacies of the GPEI run Polio program in Pakistan it paid equal justice to the Pak recent COVID-19 response. Appreciating Pakistan COVID 19 response it says, “ Whether the Pakistan response to COVID-19  is eventually judged  a  success   or  not, at  least  it seems to have resulted in a full and dynamic national engagement  with public health aspects of  the   emergency.

Many of the things that have been done (e.g. more advanced use of monitoring methods, geographic information system technology, spatial mapping) have raised their game. They have ensured that people and organizations work together”

Narrating few of the ingredients of the success Formula and appreciating the NDMA ( National Disaster Management Authority) upfront support of the pandemic the report says, “The COVID-19 crisis has had a very high level of political commitment. For example, the National Disaster Management Authority has  been engaged in the fight against the disease”.

Questions to the polio program owners

Comparing Polio program leadership vacuum with COVID19 response the highly influential group of independent experts put some simple yet worth thinking questions to the program owners:

  1. Can the approach to polio eradication  in Pakistan be “elevated” to the same degree as its COVID-19 response?
  2. Can Pakistan   instill the   same   sense   of “national emergency” for polio that has never really been there before?
  3. How does   the   Government of Pakistan react to what is being said of them i.e. “If they can pull out all the stops for COVID-19, doesn’t it demonstrate that they weren’t pulling out all of the stops for polio?”
  4. Will   Pakistan really capitalize and  learn lessons?”

The IMB laid the foundation for a debate to compare the two emergencies and further explore lesson from  Pakistan COVID 19 response for reforming the Polio program. Apart from the reasons spelled out by IMB there were visible reasons at strategic, management, operational and community level which led to the success of COVID 19 response, mentioned below:

Strategic level polio

Right from the start of the pandemic the top national civil and military leadership had developed a clear vision. There was ample unity in all sate pillars and vision was shared by all alike. A quick but comprehensive and “ fit for Purpose” national strategy was developed by engaging all key actors and wide range of independent experts. A nerve center for the operation – NCOC- was developed and operationalized with the speed of light.

Both civil and military leadership at national and provincial levels were put on board- save some political skirmishes which is all but natural- there was national unity on the modus operandi. Ideally it was a health issue and should have been led by the health sector but since there were some gaps in the capacity and delivery of health the charge was given to the planning and development ministry who could run it to perfection- bringing the government- corporate and business enterprise skills mix to beautiful execution.

The winning spirit was installed by the prime minister of Pakistan who himself led, monitored, and guided the country response. True to his cricketing reputation of “ Man of Crisis” this pandemic offered him a perfect pitch to bat on with all powers of mind, soul and heart and he paid justice to the job.

The vision provided by PM had faced ferocious resistance from political forces, technical experts, and even international agencies like WHO. It was a tough time for the country and the best test for any one’s leadership skills , a minor act of omission or commission could have far reaching national, political, economical and humanitarian consequences.

Read More: The rise of Polio cases in Sindh: Tall claims by government rendered moot

Many of his friends tried to persuade him for a change of course and to move with the tide but having “Tawakul in Allah” and confidence in his vision he resisted and steered the response ahead which ultimately surprised the whole world and Pakistan model was considered the right approach. All state organs were sold on the vision and the provinces and district authorities worked hard in tandem to minimize human sufferings.

To augment the technical capacity an internationally renowned infectious disease specialist – Dr.Faisal Sultan- who was working as CEO in Shaukat Khaum Memorial cancer hospital- was appointed as PM focal person for the pandemic. This worked out to the advantage of the program and with support of other technical experts a quick but comprehensive response action plan was developed.

Management level polio

The government created sound coordination between health ministry and NDMA and that working mechanism paid the dividend. NDMA utilizing its internal capacity, swift actions, proper resource management and  prompt supplies, implemented the national action plan to the best of their capabilities. At the provincial level CMs and Chief Secretaries were proactively leading the response with utmost dedication and commitment, similarly at the district level the whole government machinery was thoroughly engaged in the response.

The hallmark of the response was its integration with “ EHSAS Program” which created avenues for ameliorating the living condition of the “ poorest of the Poor” by injecting quick financial support to the poor families. The Pakistan response management model was unique in spirit and substance , on one hand it was managing the spread, ill affects of the pandemic – swiftly developing technical, logistical and infrastructure capacity of the health system- and on the other managing the affects of  extreme poverty that this pandemic multiplied.

The NCOC provided a coordination platform for national -provincial and civil- military leadership to get to one page and work harmoniously on this pandemic. The daily reviews, feed backs, division of labour, media briefs and follow up with government as the lead in all domains  are some of the success factors of this response. Since it was all government steered there was a visible Unity of command though all partners and international agencies were duly taken on board.

Operational level 

While the eyes were fixed on the big picture there was all attention to the minutest of details. A response that was hailed as the most efficient and effective on many accounts was based on the philosophy of “ better doing small than thinking for ages and delivering nothing”. The execution, speed, efficiency, and monitoring were simply magnificent. Rather than resorting to needless unproductive exhaustive meetings  it focused more on actions rather than words.

It was a one window, government managed and partners supported operation rather than vice versa.

Led by a compelling vision and “powerful national narrative” the response was adjudged as super-efficient that could manage the pandemic despite resource constraints, political challenges, capacity issues and traditional community skepticism,  in record time. Sleeves were rolled up, all boots on the grounds and mid night oil was burnt by everyone engaged  in the response.

Community level 

Changing the community perceptions and attitude is a tedious and complicated task , that even with the best strategies takes ages.

In this case even it was harder since this was a new phenomenon, there was lack of clarity on many issues and with no medical prevention avaible the only tools available were related to individual behavior, response and community education.

Traditionally our society in general and the less educated in particular have been proved to be the most difficult to accept change, be it family planning, female education, polio vaccination or something else and COVID 19 wasn’t an exception. We witnessed initial confusion, resistance but the program utilized all avenues for spreading information , convincing people to adopt precautionary measures and remain indoor.

The urgency to find, trace and record cases was simply exemplary, kudos to the unsung Polio workers for their dedication and commitment in supporting this . Modern use of technology, geo mapping, geo fencing were carried out with support of country premier intelligence agency and that was the reason that near to accurate information was generated and disseminated to policy makers and other stakeholders.

This author had developed the response strategy in the initial phase in which besides other points inputs for a robust and “fit for purpose” response the threat of “infodemia” and ways to manage it were also highlighted.

The government response was superb  and one source of national information – NCOC- was adopted  and that way the threat was some how managed. The Prime minster and  his team  took the responsibility and frequently interacted with Media and public to disseminate the strategies, the progress and bottlenecks and those interactions paid off.

The national media at large too played a positive role sensing the onerous of responsibility on their shoulders for this national cause there was an intentional attempt by myriads of media outlets to convey real situation and to criticize where its due- more on merit than on its own agendas.

The Pakistan COVID response case was taken as a success story

Contrary to the WHO and other warnings that August would be a highly critical month for Pakistan and an unprecedented rise in cases would take place the nation witnesses a slowdown of the cases and a descending epicurve. The Pakistan response case was taken as one of the success stories by academia, high profile bodies and personalities and international media.

WHO DG Dr. Tedros, Bill and Melinda Gates Chairperson Mr. Bill Gates and UN security council president to name a few showered lavish praises on the Pakistan Government response and its leadership? A news story in Wall street journal recognized government leadership role and its strategies to this pandemic. WHO has ranked Pakistan in the top 6 countries to which the world should look for learning on a successful pandemic response?

No doubt that COVID-19 Pandemic inflicted huge human, financial and opportunity costs but the silver lining is that investing in public health has emerged a profitable investment. It dawned upon national and international leaders that enlightened health leadership, enhanced and sustained government support, prioritizing public health on national development agenda and building health system capacity for future   pandemic and emergencies should  be seriously deliberated and prioritized.

This pandemic also provided an opportunity to move out of our comfort zone, pity agendas and work harmoniously under government leadership for the country. The country national spirit has previously beaten harsh calamities like “wave of Terrorisms in wake of the War on terror”, the 2005 Earth quack, 2010 floods and the new jewel in its crown is the national response to Corona. All this speak that when we are united, guided by a clear national vision, led by a visionary leader and  bonded by a new social contract, Pakistanis are the best and can prove their mettle in Polio, dengue, Pneumonia and other killer diseases.

Let’s keep our hopes alive that Polio program would learn from the lessons of COVID-19 response , tailor it to the best use of the program, redefine its strategic architecture, allow government to manage the program, revisit its operations and communication strategies and work in tandem with other health interventions to reach a win win.

Once these fundamental reforms in the program are enacted, next year when the IMB report would be published the Pakistan program has every reason to be labelled  “on a winning trajectory of unprecedented scale” and a great learning model .

Let’s commit that our thinking, words and actions speak for national interests .

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.