IN May, when 54 polio cases had been diagnosed in Pakistan, the agency charged with monitoring eradication efforts, the World Health Organisation’s Independent Monitoring Board, described the situation as “dire”. The IMB accused the government of “shadow-boxing” against the virus and urged the establishment of emergency monitoring cells and the direct involvement of the prime minister.
Pakistan followed those recommendations. However, as the IMB prepares to meet today, the number of polio cases has more than trebled, to 174, with cases detected in Punjab and Balochistan, earlier assumed to be polio-free. The government is, understandably, nervous about the meeting.
The current eradication programme, even following IMB recommendations, has not been effective. It will remain this way, despite increasing anti-polio campaigns, monitoring committees, and the intimidation of recalcitrant patients. The design and strategy mean the programme has no hope of success; at best, it is ineffective. At worst, it is exacerbating the problem.
One of the most serious problems begins with the very nature of these efforts. The Polio Eradication Initiative is a vertical programme —structurally and operationally outside the routine service-delivery system. It has its own funding, implementation plans, and personnel, supported mostly by donor funding with little provincial involvement. Vertical programmes have a history of success, when they provide brief, intense, focused activities in well-defined geographic locations for well-defined populations. Vertical programmes exist to support or add to routine health services; they are never meant to replace or substitute for them.
A desperate campaign will not eliminate polio.
A communicable disease like polio is controlled by creating “herd immunity” — effective vaccination of around 90pc of the vulnerable population. The “vulnerable population” for polio is large; a new cohort is added each year, meaning that creating herd immunity is not a small, focused task that can be handled by a vertical programme conducting campaigns. They have had limited usefulness in certain cases, but the current situation requires far more than a desperate campaign with an ever-increasing target.
The only real solution is a stable, consistent delivery system responsive to the needs of recipients and providers and that can earn people’s trust. This system is missing here, and no one seems interested in building it.
The problems in the service delivery system have been clear for decades. Problems exist on the supply side — in the timely transport, cold-chain maintenance, and supply of vaccines.
On the demand side, information about the nature of the vaccine is unavailable or incorrect; the programmes do not have enough staff, and those they have are poorly trained and paid; and people do not trust the authorities who rush to provide unidentifiable drops while most other forms of healthcare are unavailable.
The 2013-2017 Emergency Plan for Polio Eradication, at a cost of $328.8 million, remains silent on how these issues will be addressed. But the donors increase the funding, the government increases the target population, and everyone, including the technical consultants, the experts, and policymakers who continue to push this strategy, is content that something is being done. Eventually, something has to work, after all.
The government is reacting blindly, in a panic — it wants to be seen as doing something. Unfortunately, squeezing drops into children’s mouths from the back of a truck is not a workable long-term strategy. One dose of OPV does not confer immunity.
Dropping pamphlets from aeroplanes, in a country with low literacy rates, does not provide useful information. The country is paying a heavy price for these photo ops — including the campaign workers, many of whom have been killed while working in anti-polio drives. That is leaving aside the opportunity cost — in time, in lives, in dollars.
The polio eradication programme cannot be simply a super-sized version of what has come before. It has to be completely rethought. Eliminating polio in Pakistan requires an indigenous, contextually appropriate programme based on the routine service delivery system — supplemented, not replaced, by vertical programmes.
Given the diversity of the target population, provinces and districts will need specific activities appropriate to their environments. Donors must tie their funding to concrete, sensible efforts — including the unglamorous and un-photogenic matter of staff salaries and administrative mechanisms.
Among its specific suggestions, the IMB included in May an abstract request for “transformative action”. That, perhaps because it was more difficult than establishing a monitoring cell, has not yet happened. But without such transformative action, Pakistan will just keep on shadow-boxing. There may be some good photo-ops along the way. There will not, however, be victory.
The writer, a public health physician, is the author of So Much Aid, So Little Development: Stories from Pakistan.
Published in Dawn, September 30th, 2014