How to fix Pakistan’s polio eradication disaster

In its most recent report on polio eradication, the Independent Monitoring Board (IMB) has aptly summed up the situation in Pakistan as a “disaster”. This verdict should come as no surprise to an observer of Pakistan’s efforts ; the IMB’s plea for “transformative action” should be equally unsurprising. The IMB now believes it has found the needed transformation: Its unexpected recommendation is that polio eradication be handed over from the current authorities to the National Disaster Management Authority (NDMA).

It remains to be seen whether the government will jump on this new bandwagon. Even leaving aside the fact that a chronic, human-made crisis like polio has very little in common with an acute, sudden-onset emergency like a flood or an earthquake, making polio eradication an NDMA responsibility cannot honestly be expected to achieve the success anyone is seeking. This recommendation is yet another example of conducting a desperate search for a silver bullet that does not exist.

We are familiar with the mundane, prosaic reasons behind the continued failure since decades and millions of dollars worth of polio eradication efforts going to waste: weak administrative systems, poor training and inadequate staff. Something transformative is obviously needed but there are no quick fixes. Fixing these problems requires thinking in the long-term and undertaking systemic improvements in each of the many pieces of this puzzle. A stable routine vaccination system — which requires surveillance, contact tracing, training and treatment — is only one such piece.

The NDMA does not have the required resources and will have to work through the provincial governments’ administrative systems and technical staff. Putting polio in its hands would be a cosmetic change; it would address a few of the — well-documented and very real — management issues and maybe lead to some marginal improvement, but would not achieve its goal.

It does not really matter which department is put in charge of polio eradication, because the underlying strategy and programming is fundamentally flawed, and no one is trying to transform that.

The major flaw in the polio eradication strategy is that it depends only on a vertical programme, and does not have the solid base of a routine vaccination system. Like all vertical programmes, which have independent structures and funding, the polio eradication programme is operationally outside the routine service delivery system. Since it is urgent and visible — not to mention headline-fodder — it becomes the sole focus, to the further detriment of the already crumbling routine vaccination system. The experience of using vertical programmes in other parts of the world has shown that they deliver best when used as short, intense, focused activity in well-defined geographic locations and for well-defined populations. Their activities make sense when used to support or add to the routine services and are never to be a substitute for routine consistent vaccinations. Unfortunately, in Pakistan, the vertical programme acts alone. It is not up to task, as shown by the spread of poliovirus to Punjab and Balochistan, which were polio-free at the beginning of 2014.

We know how to control polio: The only option is to create herd immunity by vaccinating about 90 per cent of the vulnerable population, at least. This requires a stable, consistent health-delivery system that is trusted by the people it serves. Sporadic polio campaigns are not the answer, no matter which agency manages them or how much money is pumped into them. Campaigns and vertical programme activities can help, of course, but at the moment, they are like carts without a horse. You can buy more and more carts, make them nicer — but without a horse, they aren’t going anywhere.

The IMB’s understanding of the situation is unquestionable — decades of polio eradication efforts have failed and Pakistani poliovirus has affected children in Afghanistan, as well as in the Middle East, undoing the gains other countries achieved at huge cost and effort. Something in all of this needs to change now — but the change has to be at the bottom, not at the top. What needs to change is what we are doing, not who is doing it. After all this time, we need something much, much more transformative than a change in management.

Published in The Express Tribune, November 15^th, 2014.

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