‘Strategy’ problem

December 02, 2019

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The writer is an author, a public health physician and research fellow at Lums.
The writer is an author, a public health physician and research fellow at Lums.

SOME facts that have emerged from the polio eradication experience across the world, including Pakistan, must be kept in mind. There are what economists call ‘binding constraints’ regarding polio. Any change in the value of this constraint changes the outcome.

One binding constraint, given the abysmal sanitation conditions in most Pakistani communities, is the persistent reservoir of virus in the environment. The other is that rural parents lack knowledge of vaccine-preventable diseases, of their side effects and schedule. They are ignorant of the concept or mechanism of prevention; they think vaccine is medicine only for sick children. This knowledge vacuum is filled by fear of the unknown and misinformation, TV ads and radio announcements notwithstanding. This constraint causes vaccine refusals.

The government relies on bimonthly vaccination campaigns for polio eradication which though needed, cannot replace routine vaccination systems. In research funded by the Shahid Hussain Foundation, babies born in hospitals got completed first rounds of vaccination. The parents said the doctors addressed their concerns regarding vaccine safety, how the vaccines worked, and allowed them to decide without intimidating them. The parents want to continue this ‘good thing’. A health delivery system that delivers vaccines as part of the total package of maternal and child health services works. Many countries deliver vaccines to children as part of a package of comprehensive services through ‘medical homes’.

Vaccine campaigns have structural deficiencies that create hurdles in successful delivery. One is the vaccinator. The government’s cadre of vaccinators is limited, so it hires schoolteachers, Lady Health Workers and others for the campaign. Traditional vaccinator training takes a year; these workers are given one to two days of training. With only basic knowledge, they cannot satisfy parents, thus losing credibility and increasing the distrust between parents and the service system.

Polio vaccinators are poorly monitored.

Vaccinators are poorly monitored and inadequately supported. Promises of transport are sporadically fulfilled and appropriate salary, paid on time, is an ongoing issue. Since they have few stakes in the system, and are under pressure to generate numbers, they resort to aggressive tactics that backfire.

All campaigns are donor funded. For programme efficiency, and to meet donors’ requirements, activities are agreed upon at the centre, with no flexibility for change in the field; money designated for a particular activity can be used for no other. Therefore, programme managers have little authority or budgetary control in vertical programmes such as polio eradication, and are unable to solve the problems encountered in the community.

The other baffling issue is the government’s propensity to propose a ‘new strategy’ without discussing what was wrong with the old one. All new strategies are the enumeration of objectives that governments espouse, so they are neither new nor strategies. No wonder these strategies don’t work.

For example, according to the National Emergency Action Plan for Polio Eradication, 2016-17, the “goal is simple and ambitious: stop polio transmission in Pakistan by the end of 2016”. And “the programme has set up a multipronged strategy”. The strategy was: “Stop poliovirus transmission in all reservoirs; detect, contain, and eliminate poliovirus from newly infected areas; maintain and increase population immunity against polio throughout Pakistan; stop the international spread of WPV [wild poliovirus] by decreasing risk across common transnational reservoirs; sustain polio interruption through increased routine immunisation coverage in core reservoirs.”

Since that did not work, there was, without analysis of why the last one did not work, a new national emergency action plan for 2018-19. It says it would “institute large-scale vaccination activities; address miscommunication; ensure accountability; introduce new mechanisms to ensure programmes use data effectively; work with Afghanistan”. It says all this without saying how all this will be achieved. What are the new mechanisms? How will they be introduced? How will accountability be ensured or miscommunication addressed?

Now another new strategy is in the making. As polio cases continue to emerge every day, policymakers reassure donors, as in the recent Abu Dhabi meeting, and us that ‘we have conveyed to international donors that we are developing consensus among all provinces to enhance our vaccination campaign with a new strategy’.

What was wrong with your last one? Why should we believe that this new one would be any better?

A perplexing question is why policymakers continue to make grand plans that go nowhere, rather than tackling the actual problems that are staring them in the face. How do they hope to find solutions if they do not acknowledge the problems?

The writer is an author, a public health physician and research fellow at Lums.

Published in Dawn, December 2nd, 2019