FOLLOWING the World Health Organisation’s Internal Monitoring Board (IMB) meeting some time ago, the government of Pakistan is understandably embarrassed about the review of its polio eradication efforts.
Condemnation has been quick. An editorial in this paper called polio eradication the country’s “badge of shame”, blaming the government for its “stubborn, almost criminal refusal to undertake the task at hand”.
The abject failure of the government’s efforts is undeniable, but this criticism, at least, is unfair. The task at hand was undertaken, certainly — the problem lies in how, precisely, it was undertaken. Essentially, the government and the other participants in this exercise have been performing a play, in which things look more or less right but have little actual meaning. One could call it the farce of polio eradication.
For the past two decades vaccination coverage rates for polio have been less than 60pc.
Every government for the past three decades, military or civilian of whichever party, has voiced the political will to eradicate communicable diseases including polio. Donors have consistently supported Pakistan’s efforts, providing close to $9.5 billion over the past 25 years to the vaccination programme.
In the beginning, there were some gains in controlling polio. There were over 2,000 polio cases in 1988, when the programme began — but for the past two decades vaccination coverage rates have been less than 60pc nationally, which is nowhere near enough to create the needed herd immunity for protection.
When the WHO announced its Endgame Strategy, the government made a corresponding series of correct-seeming moves. This includes following specific recommendations from the IMB itself.
A National Emergency Action Plan 2014 for Polio Eradication was prepared and, fully funded until 2018, approved by the Executive Committee of the National Economic Council. Special task forces were put in place at the national and provincial levels, led by the prime minister in the centre and the chief ministers or chief secretaries in the provinces.
The prime minister appointed a dedicated point person — in addition to the minister of health services — to lead the overall effort. Monitoring committees of senior managers exist at the federal, provincial, district, tehsil and union council levels. Every province has a special polio control room. In addition, the emergency operation cells started in two provinces will now be expanded to cover all four. Anti-polio drives are being conducted according to schedule.
All the pieces, therefore, are in place, following precise recommendations from the highest authorities and the IMB. But none of them work. None of them are functional. No single government department has the overall responsibility of coordinating the actions of all these task forces and committees.
The many management committees themselves are unclear about their tasks — the National Task Force, for example, has not met since September 2013 — and no one is present to hold them accountable.
The 18th Amendment further confused the various actors about their tasks — the provincial and federal responsibilities remain unresolved. Under the current strategy, the district and tehsil-level actors have neither the resources nor the authority to actually make any decisions, so their involvement is largely superficial. Information sharing among the various levels of government is virtually impossible, let alone with the implementing partners.
The IMB has also fallen short in the review process it has been tasked with. In the recent meeting, the board should have asked the obvious questions raised by the government’s presentation, which described the overall objectives, general management plan and the challenges facing Pakistan. But it gave no immediate details or indications of how it would address the challenges and improve or amend its strategy though it plans to release a report by the end of this month.
Since this is a farce, part of the process is finger-pointing, a long-running blame game that can distract us from the failures. The provinces point at the centre. The centre points at the provinces. Everyone blames Dr Bosan, who, it seems, was heading the government’s technical unit for polio eradication while not actually being a government employee. Some pieces get shuttled around the board — Dr Bosan out, Dr Baloch in — and, why not, a new inter-ministerial committee is proposed.
This looks like much more activity than improving the administrative processes that would bring together the work of different government departments, or coordinating the efforts of the many different committees already on the ground.
It is much more dramatic than addressing the nitty-gritty issue of dealing with procedures that, for example, delay payments to polio staff. Unfortunately, it accomplishes almost nothing.
And so it should be no surprise that the number of polio cases continues to climb, reaching over 200, from 54 when the IMB last met, in May. Environmental surveillance shows that the frequency of detection has increased to 33pc from 20pc in 2013, and wild polio virus type 1 has been isolated from all four provinces.
As polio spreads, it becomes a humanitarian issue, so the donors feel compelled to increase their funds — in a very real sense rewarding the government for its failures. Giving more money is immediately reassuring, it looks better — and is less controversial than asking the government for specific actions to make programme structures functional and sustainable.
After all — you cannot give visibility to a procedural request. Neither the donors nor the IMB make it a point to insist on a country-specific, contextual programme design and implementation strategy. The IMB will meet again; it will offer some more suggestions; the government will likely follow them; and the cycle continues.
The best we can call this process is a farce, one that would be mildly entertaining if you could ignore the fact that it is costing not just money and time but lives and futures. Once you acknowledge that — perhaps then all we can call it is total madness.
The writer, a public health physician, is the author of So Much Aid, So Little Development: Stories from Pakistan.
Published in Dawn, October 20th, 2014