Author: Judy Twigg, Ph.D., June 6 2017 - works on issues of health, demographic change, and health systems reform in Russia and Eurasia, as well as evaluations of health reform and communicable disease control projects (including factors behind the polio outbreak in Ukraine) across the former Soviet Union, sub-Saharan Africa, and other parts of the world. She is professor of political science at Virginia Commonwealth University and a senior associate (non-resident) with the Russia and Eurasia Program at the Center for Strategic and International Studies.

It has become commonplace to talk about nearing the "finish line" on polio eradication, but critical challenges remain along the last mile. Courageous vaccinators confront a varied array of daily challenges and threats. Anti-vaxxers scare away vulnerable parents and families with disproven claims about links between vaccines and autism, leading to serious recent measles outbreaks in Italy and Romania, among theme park vacationers in California, and among Somali-Americans in Minnesota. Russian media groundlessly blame the neuromuscular disorder that keeps their country's 2017 Eurovision contestant in a wheelchair on the polio vaccine she received as a child. And although bipartisan support on polio remains solid in the United States, financial and technical support to other key global health initiatives is in question.

Yet glimmers - beacons, even - of hope crop up in some of the most unlikely places. One of those is today's Ukraine. In the summer of 2015, Ukraine burst onto the global polio landscape with two cases of vaccine-derived poliovirus in a western province closer to seven other European capitals than its own, Kyiv. A perfect storm of catalyzing factors had been producing increasingly desperate warnings for almost a decade from those who were paying attention. State financing for vaccines was inadequate and mistimed. The May 2008 bacterial meningitis death of a teenager in Donetsk was (wrongly) blamed on his recent vaccination for measles and rubella; the anti-vaccine sentiment that emerged was stoked by sensational news and social media, leading to a health ministry moratorium on vaccine distribution and the firing of the country's chief sanitary inspector. Health professionals grew increasingly skittish, on the hook for potential criminal prosecution in case of adverse events following immunization. Parents lost confidence in the entire system. Not surprisingly, vaccination rates plummeted, from near full compliance in the early 2000s to below half in 2013. Polio vaccines reached only 14% of infants in the first half of 2014.

The driving force underpinning this sequence of events was a coalition of importers who profited from control over procurement of vaccines and other medicines. These businesses, taking full advantage of their high-level political ties, colluded to coordinate bids and increase prices, using shell companies, repackaging/relabeling schemes, and manipulation of regulatory requirements to pocket exorbitant markups. The bottom line: already scarce government resources were stretched beyond their limits by payments far higher than was necessary for vaccines. Shortages ensued. When UNICEF [the United Nations Children's Fund] initiated international procurement in response, the corrupt middlemen reacted in defense of their interests, goading fears about vaccine toxicity and side effects through an increasingly rabid media blitz that went as far as accusing the international development community of intentional harm to Ukrainian children. They tried to counter the threat to their lucrative schemes with waves of misinformation aimed at confusing parents, dividing Ukraine's own institutions of health governance, and keeping the international community at bay.

But - and here's where the hope emerges - it didn't work. Instead, UNICEF, WHO [the World Health Organization], Rotary, and other partners, hand in hand with capable allies in the health ministry, launched a three-round polio vaccination campaign in late 2015 and early 2016 that eventually reached over 80% of Ukraine's children. A national and international spotlight was thrown on the potentially devastating human impact of the country's crisis of corruption. An independent, energetic new acting health minister - Dr. Ulana Suprun, a Ukrainian-American physician who had relocated to Kyiv during the Euromaidan - was brought on board to tackle the problem, and she has acted with remarkable vigor. She and her young, reform-minded team, working with the full support of the Prime Minister, have collaborated with leading anti-corruption NGOs [non-governmental organisations] to restore integrity and predictability to vaccine supply. A multi-year mechanism is now in place for international drug procurement, with transition arrangements well underway to build sustainable capacity and legitimacy among Ukraine's own procurement institutions.

Even further, these positive developments with vaccines and procurement have cascaded into a series of actions impacting the entire health sector. They helped to ignite momentum for broader change. Long-standing calls for health sector reform, to push past the inefficient legacies of a long-obsolete Soviet model, appear finally to have gained real traction. Landmark health reform legislation is now on its way through the approval process, designed to ensure availability of essential inputs, revamp primary care and overall service delivery, restructure health care financing, and promote quality governance of the sector. For the first time, the political will to remake Ukraine's health care system has coalesced, and targeted international support - from the World Bank, USAID [the United States Agency for International Development], and others - is lining up to make sure it sticks.

Ukraine's health sector is a work in progress, and the story is far from over. The political and security environment in Ukraine is still challenging, and there are plenty of vested interests in preserving old habits and privileges. But it's entirely possible that, at the end of the day, this will be a story of a polio crisis serving as one catalyst for a broad health sector restructuring that stabilizes vaccine procurement, increases access, efficiency, and quality of health services, and improves health outcomes. With the right kind of sustained investment and support, Ukraine will be a case study of work for polio eradication producing hope not only for polio, but for essential health system strengthening across the board.

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