Why are we failing to eradicate polio?
The writer is an Adjunct Professor of Epidemiology at the University of Nebraska and has worked for the US Centers for Disease Control and Prevention. He can be reached at jasghar@gmail.com
On the International Day for Polio, Pakistan got an unfortunate distinction. We identified another polio case, totaling 40 so far this year. Despite the successive governments declaring Polio as a high priority and a national emergency, we are completely failing in polio eradication, even though we were so close a few times. Not only do we have 40 positive cases of polio, but we have more than seventy districts infected with the lethal virus. Each positive case of polio means 50 to 500 cases in the community who are infected and may be spreading the diseases; but since they themselves may have mild or no symptoms, they escaped the polio surveillance system.
According to a news report, Pakistan spends more on polio eradication than the whole immunisation programme, which covers nine different diseases. Even though most of the funding for polio comes from international donors or through soft loans, it is still a whopping Rs52 billion. Just the World Bank spent close to $300 million in Pakistan from 2003-2017 on polio. In 2022, the Gates Foundation pledged $1.2 billion to support polio eradication. With all this attention and resources, we should have been moving to one trajectory, but that is not happening. So, who is responsible? Pakistan or international donors?
It's not new or unique that international donors always blame host governments when things go wrong. The same is the situation now, as international donors are blaming the Pakistani government for this colossal failure. Pakistani officials are privately blaming donor agencies as being deeply involved in not only strategy development but also in implementation and monitoring with opaque financial information. I agree completely that the government has a fair share of this failure, but it's not alone. The International Monitoring Board (IMB), which oversees polio eradication efforts around the world, in its 2019 report identified key reasons for failure in polio eradication. And one was the failure of the top brass to listen to their field force. With rigidity and some sort of holiness, the polio programme follows the guidelines and strategies developed overseas, which have limited input from the ground. When ground feedback is not getting its due attention, the field workforce just follows the orders, even knowing it does not make sense. The outcome: we miss nearly 4 million children. The bigger problem is that even with successive immunisation drives, the same children are missing again and again. To avoid this situation we need to have updated area maps and extensive planning before every drive. Vaccine hesitancy or refusal is blamed but the scale of this problem may be overly exaggerated.
Enough of problems. What is the way out? The Government of Pakistan needs to nationalise the polio programme. This means the government should start paying for the polio programme directly. It should hire the best public health professionals from Pakistan to run its polio programme. The polio eradication strategy needs to be developed from the ground with a bottom-up approach. International health agencies and donor organisations should be partners in this effort, but Pakistan needs to take meaningful leadership of the programme.
International donors need to be reached out to renegotiate their resource allocations. The polio programme should not stay as a vertical programme but be a part of a strengthened routine immunisation programme. Once it becomes part of routine immunisation, there will be less hostility, as the focus would be on the overall health of a child and not on a single disease. There is a need for transparency in how resources are allocated and spent in the programme by all partners. People responsible for the polio eradication programme at the global level want to keep the programme vertical as they fear that it will lose its focus and may lengthen the journey towards eradication. But if something is not working for that long, we need to do something different. Immunisation and polio synergy have been their favorite mantra for years on paper. Now they need to practice it too, not only for polio eradication but to save the lives of kids from other childhood diseases too.