The continuing polio debacle

Pakistan’s polio debacle continues to fester. In 2004, Pakistan was on the brink of being clean but failed, and the virus is now being exported to other countries. The World Health Organisation (WHO) has declared a health emergency, clamping travel restrictions on Pakistanis. These, in turn, have generated separate implementation challenges for the government.

For those who have followed the polio eradication campaigns closely, the challenges are evident and well known. Fixed centres are short of supplies; staff trained by donors is sitting idle, creating fictitious reports; parents who show up are turned away.

Other more immediate challenges are voiced during vaccination campaigns. Recently, health workers in Kohat refused to participate in a polio eradication drive because they had not been paid their salaries since January. In Khyber-Pakhtunkhwa, three health technicians were charged with murder because they had caused the death of children due to incorrect administration of vaccine. Close to 150 government employees have been arrested for corruption during vaccination campaigns.

These challenges, along with poor vaccination coverage rates, is not new information. Coverage rates in Pakistan have not been more than 50 per cent for the past two decades. Moreover, they range from as low as 26 per cent in poor communities to 66 per cent in affluent ones. Programme evaluators have voiced reservations about the ability of the programme to achieve its objectives for many years.

On the other hand, negativity stemming from religious beliefs is a minor issue admitted by the government — 0.5 per cent of vaccination refusals are on religious grounds despite the fact that close to a hundred fatwas have been rendered by religious scholars in support of the vaccinations.

How polio spreads and the measures to counter its spread are well known as are the facts and challenges. The question is, how are the authorities planning to overcome these problems?

All governments for the past two decades have supported polio eradication efforts. The current government has also prepared a plan — the 2014 Peshawar Plan for polio eradication — just as the previous one prepared a National Emergency Plan for Polio Eradication in 2011. Unfortunately, the 2014 plan, like the 2011 one, is not likely to achieve the intended results. It, too, seems set to fail and for the same reasons. These plans are too abstract and unrealistic and do not articulate a coherent strategy to overcome the challenges that are being brought to the government’s notice even as we speak.

The 2014 Peshawar Plan ignores the field implementation challenges staring it in the face. Instead, it focuses on capital outlays — equipment and supplies — that are outsourced to donors. It continues to rely on a top-heavy management structure that ensures confusion and fragmentation. The Peshawar Plan has multiples of five management committees at each level — federal, provincial, district, tehsil and union council — with overlapping responsibilities to the extent that it is not possible to determine who is actually in charge and of what. Even the deputy commissioner and superintendent police make cameo appearances as responsible parties.

Critical field level needs have been ignored in the plan repeatedly. The plan lacks assessment of the number of staff needed in specific categories such as supervisors and monitors. It does not include a strategy for maintenance of the cold chain beyond the district level. All these are the responsibility of the government to evaluate and provide since donors do not provide support for these.

The Peshawar Plan should lead with these practical issues of field implementation. Without these, there can be no sensible resource mobilisation and no district level implementation strategies. In the absence of the latter, all the big words and fatwas will do little to alleviate the polio predicament. The global community might succeed in bottling it up into a local problem by monitoring international travel. Polio vaccines will then attain the status of clean drinking water — available to the affluent while the poor continue to die of preventable waterborne diseases. Welcome to Pakistan.

Published in The Express Tribune, July 2^nd, 2014.

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