THE ROCKY ROAD TO ZERO: 11th REPORT OF THE INDEPENDENT MONITORING BOARD OF THE GLOBAL POLIO ERADICATION INITIATIVE

Sunday, 24th of May 2015

THE ROCKY ROAD TO ZERO: 11^th REPORT OF THE INDEPENDENT MONITORING BOARD OF THE GLOBAL POLIO ERADICATION INITIATIVE

Excerpts below from introduction and Pakistan and Nigeria chapters; full text is at http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/12IMBMeeting/12IMB_Report_EN.pdf

The Independent Monitoring Board provides an independent assessment of the progress being made by the Global Polio Eradication Initiative in the detection and interruption of polio transmission globally. This eleventh report follows the IMB twelfth meeting, held in Abu Dhabi on 29 and 30 April 2015.

INTRODUCTION: IT WAS NEVER GOING TO BE EASY

The last report of the Independent Board (IMB) of the Global Polio Eradication initiative (GPEI), published in October 2014, was clear that the programme goal of interrupting polio transmission globally by the end of 2014 would not be met. This assessment was confirmed as 2015 began and children were still being paralysed by polio.

Nobody expressed great surprise, accustomed to the sad reality that the polio programme has missed one deadline after another.

Despite this, 2015 has brought a spIrit of optimism to the programme. Since August 2014, the wild polio virus has been detected in just two countries, Afghanistan and Pakistan. Nigeria – long the third endemic country – has

not had a case since July 2014. The three recent regional outbreaks – in the Middle East, the Horn of Africa, and Central Africa – have been quiescent since that time. At the time of writing, there have been just 23 children paralysed by polio so far this year – there had been 77 at this point last year.

Optimism is a double-edged sword for this programme. There is real and genuine progress to be positive about. But the IMB recalls three years ago, in 2012, when optimism last soared. That year, case numbers plummeted. There were no outbreaks outside of the endemic countries. The programme seemed to be on the up. But this optimism was misplaced – 2013 and 2014 brought a wave of three major multi-country outbreaks, growth in global polio case numbers, and a series of difficult new challenges for the programme.

Overall, the global programme in 2015 is a better one than when the IMB started its work nearly five years ago. The programmes progress is a predictable and direct result of following advice and adopting new ways of working. The programme has responded well to the challenges set by the

IMB in a number of domains, particularly:

• Understanding and addressing the reasons why children are repeatedly missed by vaccination campaigns

• Strengthening accountability throughout the programme, so that expectations are clear and enforced

• Improving collaborative working between partners, so that the strengths of each can contribute to the effort as a whole

• Getting the best staff to the places where they are needed the most

• Putting governments in the lead of their countries polio eradication programs, with partners in support

• Enhancing urgency, so that business as usual cannot prevail

• Encouraging innovation and the spread of successful ideas

• Emphasising demand, not just supply, through stronger people-centred offerings to key population groups

• Ensuring that armed conflict and political sanctions are not allowed to be absolute barriers to reaching every child with the polio vaccine

• Focusing effort on the small geographic areas (sanctuaries) where most polio virus resides

• Putting more emphasis on outbreak preparedness and response, not allowing the endemic countries (though important) to monopolise focus.

Notably, most of these have little to do with the virus or the vaccine directly, and everything to do with people, communication and management. When these fundamentals have been addressed, progress has been seen. When they have been disregarded, progress has been slow or absent. When the global view has had a narrow focus (rather than a comprehensive approach that combines disease reduction and risk mitigation), there have been major setbacks – such as the major outbreaks of 2013.

So the current sense of optimism has some real basis to it. But the sense of optimism is also highly dangerous. The two-steps-forward-one-step-back history of the programme teaches hard lessons about assuming that plain sailing is ahead. Security, operational and political problems can suddenly arise, disrupting the programme progress. The polio virus has a habit of revealing itself in the most difficult places on earth. Hard-won success can quickly fall away. The last three years have demonstrated that the final stage of the march to polio eradication is a rocky road, as the polio virus fights to save itself from extinction.

This IMB report, more than any of its predecessors, urges the programme, at global and country level, to embrace, with determination and passion, the culture and methods of fundamental quality improvement. The global programme is better than it was, but it remains far from excellent. If it truly

aims for excellence, it can become a resilient programme with strong prospects of successfully navigating the rocky road ahead. If it does not, it will have to put its faith in being able to limp towards the finishing line despite big patches of mediocrity.

. . . .

PAKISTAN: RECENT POSITIVE MOVES BUT EARLY DAYS

In Pakistan, polio paralysed three times as many children in 2014 as it had in 2013, and the programme was floundering in response. In the meetings and discussions that preceded its last report, the IMB encountered wave after wave of negative comment about the polio programme in Pakistan.

Those who spoke did so in harsh and despairing terms, some expressing pity for the plight of the children of Pakistan. Few were prepared to make their comments openly for fear of upsetting the government of Pakistan.

As the only truly independent element of the polio programme, free of any stake in its planning and delivery, the IMB had no choice other than, very publicly, to “speak truth to power.” It did so exposing the fundamental

weaknesses of the polio programme in Pakistan. The IMB recommended changes aimed not at simply strengthening the programme but putting it on a national emergency footing. The government of Pakistan did not accept the

IMBs recommendation but has found and adopted an alternative approach that it feels will have the same impact.

Six months on, a positive difference is evident. The signs of improvement are early but clear. Crucial amongst these is that the government of Pakistan has taken hold of the reins of polio eradication. The Prime Minister has established

a Focus Group, to drive the programme from the highest possible level. The newly established national Emergency Operations Centre is working well, with strong leadership from the government and support from partners. There is a real sense of collaboration – between the different parties that govern the country and its provinces; between the civil administration and the military; and, between the programme partners. The IMB met with senior federal and

provincial leaders, and was impressed with their insights into the polio eradication context and their determination to improve the situation.

It is very early days. The Pakistan programme is still moving through the foothills of a very high mountain that is still to be climbed. Many basic dysfunctions remain. In some areas, half of all microplans used in campaigns are out of date. Whole settlements are being discovered that were previously

being missed by vaccinators. Most of the provincial Emergency Operating Centres have only been properly established in recent weeks. Similar ways of working need to penetrate well beyond the federal and provincial levels, into

the districts and union councils where polio remains at large. The programme does not pay its front-line workers reliably. This must be resolved – and urgently. The Pakistan programme has ideas to boost the morale, engagement and status of its all-important vaccinators, but this will be wishful thinking unless the serious demotivator – not being paid in full and on time – is properly done away with.In taking the next steps to build on this new impetus, it is important for the programme at country level to truly understand the social geography in the affected areas. There is innovation in place addressing some local situations, such as offering a broader package of services than polio vaccine (so-called Health Camps). Such innovation must continue.

Pakistan must not duck out of facing up to the fundamental barriers to reaching children, nor must it continue to reach for tired and unimaginative solutions that have failed in the past. Whilst the majority of Pakistan is free from polio, and has been for some time, the challenge of eradicating polio

from a small number of geographical areas where it persists is formidable. In most of the country, children are being reliably vaccinated against polio. But in too many, children are being persistently missed.

NIGERIA: BUILDING RESILIENCE TO STAY POLIO-FREE UNTIL 2017

In its last report, the IMB praised the Nigeria programme for staying free of wild polio virus for three months. This period has now extended to ten months. Nigeria polio virus has regularly infected other African countries in the past, but that has not happened for more than a year now. No circulating vaccine-derived polio virus has been detected since January 2015. The Nigerian general election has come and gone without the deterioration in programme performance that accompanied past elections.

The improvements in the Nigeria programme are most evident in the large jumps in immunity achieved in the worst performing local government areas.

The most important factors in Nigerias progress to date seem to have been: firstly, the establishment of Emergency Operations Centres (EOCs) that have transformed the quality of planning, decision-making, coordination and inter-agency working; secondly, embracing an approach of innovation and rapid scale-up; and, thirdly, addressing poor individual performance.

Some press coverage has suggested that the country has already rid itself of polio. This is dangerous thinking. The challenge for the Nigeria programme is now one of resilience. Certification of a polio-free Nigeria cannot happen until 2017. Excellent programme performance is as vital over the next three years as it has been over the last three years.

The area with greatest vulnerability is the Northeast of the country. Here, 62% of settlements remain inaccessible to vaccinators. This creates worrying blindspots for the programme. There is an urgent need to establish who is living where, and to reinstitute vaccination campaigns that run as close to normally as is achievable. This requires innovation, and a willingness to reach out to a range of partners. Strong surveillance is also crucial, so that Nigeria can quickly respond to any polio presence. Surveillance is generally strong, but there are still areas of weakness that need to be addressed. There were 35 compatible cases in 2014, demonstrating surveillance gaps. The programme has identified 40 Local Government Areas in which surveillance needs to be improved.

A great deal rests in the hands of Nigerias new government. With strong commitment, there is good potential that Nigeria will eradicate polio within their term, and will be able to celebrate a great Nigerian victory. But if the polio programme loses momentum or support, the country could be responsible not only for polio coming back to Nigeria, but elsewhere in Africa too.

India faced and met the challenge of staying polio-free between its last detected case and its official polio-free declaration. The IMB judges that Nigeria currently falls short of the levels of programmatic excellence achieved in India.

The areas of risk we have described mean that Nigeria is not yet safe. Nigeria must build further resilience and, over the next six months, move its programme from good to great. The IMB is very concerned that national, state and local government politicians, as well as the Nigerian public, will now start to believe that polio is gone permanently from Nigeria. It needs to be made absolutely clear that Nigeria has not yet been certified polio-free. The programme and its partners need a clear, coordinated communication and advocacy plan to ensure that the public and political leaders understand the substantial work that lies ahead. In the meantime, the growing triumphalism surrounding the prospect of a polio-free Africa must be halted.