Author: Sue Goldstein, May 21 2015 - "Of the 19.3 million children under-immunized with DTP-3 in 2010, 6.6 million were in Africa and 60% of those children lived in only five countries. The availability of vaccines is not the major problem - it is the delivery systems, a trained workforce to deliver the vaccines, and a participating community that are most desperately needed.1"
The polio eradication programme is in its final stages, reaching the last of the circulating wild virus in the few remaining countries - or is it? Certainly, countless lives have been saved and disabilities prevented through the eradication programme, and eradication is closer than ever before. The eradication, apart from getting to every child in the last endemic countries also is very dependent on non-endemic countries maintaining high levels of polio immunity. Given outbreaks in the horn of Africa and post-Ebola breakdown of services, many unvaccinated children in areas of instability such as the Ukraine are at risk of further outbreaks - a risk that is still high and real. One has to ask: is it worthwhile? There are many who ask if the world should have focussed instead on improving routine immunisation (RI) coverage, thus saving many more lives and improving the health and quality of life of millions of children under the age of 5 years and their parents. It is the age-old discussion about vertical programmes versus building strong, integrated health systems.
As interesting and important as this question may be, the reasons for focusing on polio are historic and now irreversible, so the question I'd like to explore is: What can be learned from the polio eradication campaign that can contribute to improved RI coverage going forward?
An important lesson is focus. The polio eradication campaign is very focussed - on one disease always, and geographically gradually from global to a few countries, a few districts in these countries, and a few sub-districts in those districts. It sounds very simple, but, in fact, the information chain is a critical part of the process of keeping this focus and narrowing it over time. The emphasis has been on the use of data in identifying surveillance gaps, quality of campaigns, number of children reached, numbers missed, and the reasons for those being missed. This data has been collected and promptly fed back into the system to rectify problems and to enable risks to be identified. This has been done by ensuring that reporting is timely, surveillance is good, endless rounds of polio immunisation are carried out, and unimmunised children are continuously identified and immunised. As focus gets narrower, the task gets harder.
Of course, the single disease element of this focus is also one of the contentious issues. Should so much time, money, and effort be put into eradicating one disease when there are so many other priorities for the very people who are hard to reach? In some countries, such as Nigeria, the integration of polio immunisation into broader child health days has improved the public perception of the programme and improved uptake, as well as improving child health. Engaging with communities who appeared to be resistant to polio immunisation was an important step in the understanding that parents have broad priorities to enable the full participation the programme needs to understand these needs and at least partly address them. The single disease focus has had a number of successes - for example, the treatment of AIDS in South Africa - but, even then, the single focus doesn't come without its problems. For example, getting TB diagnosis and treatment integrated into the AIDS programme has not been easy, despite the fact that it is the biggest killer of people living with HIV in sub Saharan Africa. Similarly, integrating sexual and reproductive health services and the AIDS services has not been smooth, despite the very high maternal mortality rate and the obvious connection with the AIDS epidemic. However, the single focus has enabled a lot of money and skills to be developed in South Africa, which with care will be interwoven into health services.
It took some time for the polio eradication initiative (PEI) to recognise the importance of integration of communication at a number of levels at the outset of a campaign, using a social change model that works at the level of the individual, the community, and the broader society. Developing an approach where the starting point was an in-depth understanding of the parents and communities of the children who need to be immunised was a critical lesson learnt. Integrating the communication aspect with the implementation arm, working with communities and understanding their priorities, communicating in ways that are meaningful to them - these are all key aspects of gaining community support and higher reach, but not something that came naturally or quickly to the PEI (or other health programmes, for that matter). Often, the communication is separate from programmes, the advocacy and social mobilisation components are separated, and communities are left out of the planning processes. India is a good example of a shift to a better integrated model using a Social Mobilisation Network (SMNet), which had the following approach (1) cadres of trusted community mobilizers who track children's immunization status, (2) responsiveness to people's concerns about immunization, (3) outreach to religious and other local leaders, (4) focus on both individual- and community-level behavioral approaches, and (5) continuous data collection and use. Using this approach for health in general could be a game-changer for many lower-resourced countries with hard-to-reach populations. The other aspect of integration which is often neglected (in both health services and campaigns) is communication with health workers and motivation of frontline workers.
Measurement - the constant measurement process of the polio eradication campaign is one of the major ways that the eradication is being achieved - we know very quickly where there are new cases, where the risk areas are, and where the unimmunised children are. We know why parents are refusing immunisation and where the hard-to-reach children are. Do we know this about RI? We do collect routine statistics, but it is well known that many of these are unreliable and the denominators unclear. Part of the reason for this is the lack of political will and understanding on the part of health workers of the value of immunisation and that of measurement. Measurement is seen as a threat and a tool that managers will use to punish the services, rather than a useful tool. Often, people are not sufficiently numerate and trained in data collection and use. (The data is collected and passed onto the next level and not used at the facility and/or community level.) The more that communities are engaged in monitoring their health status and services, they will be enabled to demand improved quality of services, including immunisation.2
Quality control is something many health services haven't dealt with adequately - and, certainly, communication programmes rarely deal with. Ongoing monitoring of audience reception, of how people get their information, of the content of community and religious meetings are all areas rarely followed through. The PEI monitoring of the quality of campaigns has more recently brought about great strides in how campaigns are implemented: independent monitoring, quality control tools, and dashboards indicating quality of reach of campaigns and quality of surveillance. These approaches can all be adapted and used to improve RI.
Politics and political will - something that the polio campaign has constantly had to deal with (including open hostility and killings of polio campaigners/ health workers). Health is not neutral and certainly not divorced from the political economy or social construction of the society. Making a financial case and putting pressure upon the international and internal communities can be helpful in changing the political commitment to RI, but training in advocacy within the country immunisation communication teams is critical to this being implemented well.
Understanding the mobility of populations - both in-country and between countries - is important in controlling any illness, but in an eradication programme it cannot be underestimated. This of course is only important when there are large populations of unimmunised children (a ready breeding ground for a transported virus or bacteria). In countries where large numbers of people are mobile; in fact, across regions such as the Southern African Development Community (SADC) region, routine services need to take account of mobile people, enabling their children to be protected by RI. Regional strategies need to be developed, which would include harmonised immunisation schedules, patient-retained child health cards, etc.
Champions are important to drive the campaigns - not necessarily high-profile, but committed and well-placed champions at different levels (international, regional, nationa,l and local) to keep the issue on the agenda constantly.
Finance: One of the biggest obstacles to RI universal coverage is financial; furthermore, the economically poorest countries have the poorest health services, and their governments do not necessarily commit the proportion of the GDP that they should to preventive services and immunisation. Ensuring that the issue of RI is on international, regional, and national agendas can, to a certain extent, shift the resources - both at the international donor level and at the national prioritisation level. Clear advocacy campaigns are needed to consistently put the health of children on the agenda. The PEI as a programme is never fully funded but always manages through a number of ways to continue operating at an effective level.
Bringing together the lessons of focus, improving measurement and use of data at all levels, developing and using quality control mechanisms, bringing on board RI champions, integrating communication into RI at all levels, using communication to garner political will and finance for universal coverage in RI will go a long way towards saving the lives of millions of children and achieving the MDG’s (and SDG's). Finally, the achievement of health for all (universal health coverage) obviously will not be achieved through the polio eradication programme. However, if we can implement the lessons learnt and use some of the resources that the PEI campaign has put in place in many countries, we will be somewhat on the way to building universal coverage of RI.
1WHO Afro-Region 2012
2Community-based monitoring programme implemented by the National Rural Health Mission of the Indian Government.
Image credit: Chris Morry