Polio eradication

As donors gear up for a final push to eradicate polio, the aid community is beginning to consider what elimination would mean for global health. Many countries’ health systems have been built or strengthened around efforts to end the disease. What happens when polio, and the billions of donor funding it garners, are gone?

Advocates and international organizations now believe the transition to a post-polio world will be a pivotal, make-or-break moment for public health. A number of efforts are underway to plan for it now, including the World Health Organization’s recent polio transition planning document, launched at the World Health Assembly last month.

In many corners of the world, polio vaccination and surveillance campaigns formed the basis of countries’ vaccination and disease prevention systems. A transition would need to ensure the systems remain robust, even as the impetus for building them fades into the background.

Donors have led the push to build those preventative health systems. On Monday, a partnership led by Rotary International and the Bill & Melinda Gates Foundation announced $1.2 billion to finance efforts to end the disease.  

If and when polio is gone, however, much of the transition may fall to national governments. International funding stands to shrink dramatically. About 27 percent of WHO’s $587 million in spending in 2016 went to polio eradication efforts.

The African region would also be particularly hard hit. Forty-four percent of WHO spending there went to polio efforts, and about 90 percent of all immunization staff and infrastructure on the continent are funded through the WHO’s Global Polio Eradication Initiative.

“Domestic investment is commendable. We need to continue to support and encourage them to get to the finish line,” outgoing WHO Director-General Margaret Chan said at the World Health Assembly.

The risks

Global polio eradication efforts, including the WHO’s Global Polio Eradication Initiative, are closely integrated with other vaccine and global health programs that could suffer setbacks as polio funding is reduced and eventually eliminated if the disease is eradicating.

Efforts to vaccinate against measles and rubella, as well as diphtheria, tetanus and pertussis, which are often prevalent in key polio transition countries, are particularly vulnerable, according to the WHO report. Disease surveillance programs and laboratory funding could also be impacted, according to the report.

Another risk is to pandemic preparedness and detection. In Nigeria, polio staff and surveillance infrastructure were key to containing Ebola during the West Africa outbreak.

WHO is working at the global, regional and national levels to plan for the transition, and has recognized the threat a mismanaged transition could pose, according to the document. For example, WHO plans to conduct a country-level analysis to plan for changes in funding post-polio, and determine what to do with certain assets, such as properties or land, which are funded through polio programs.

WHO budgets for 2018 to 2019 have already been set, without taking into account the needs of polio transition. Still, the report recommends that the director-general, who has some discretion, should set aside some funds to mitigate against risks.

According to the estimates in the WHO report, a 15 percent increase in the budget is needed to scale up surveillance, technical assistance and fund some of the shortfalls that may come from polio spending reductions. In future funding cycles, funding focused on vaccination will likely have to be increased in order to maintain systems as well, according to the report.

Efforts to get to zero

Countries still experiencing cases of polio remain focused on vaccine campaigns and other global health concerns that could impact progress. Political leadership is a key driver in some of the efforts, and will prove important in the transition.

Nigeria, for example, saw no cases of polio in 2014, but vaccination efforts stalled the following year amid violence in the northern part of the country. Health workers were killed, and many areas were unsafe or inaccessible.

The government mobilized the military to protect health workers and administer vaccines in response, Nigerian health minister Isaac Adewole told a World Health Assembly event. The government has also worked to vaccinate internally displaced people at transit points and at international borders. The military vaccinated 4,500 children in about 450 previously inaccessible settlements, the minister said. They’ve also expanded the surveillance system.

In Pakistan, making polio a political priority has helped mitigate some of the access and security issues that were stalling progress, Saira Afzal Tarar, the country’s minister of state for national health services, regulations and coordination, said at the event.

Support from political leaders as well as religious leaders, the medical community and the media have all helped, she said. The government has a single team working on the issues, and about 250,000 frontline staff have visited more than 37 million children under the age of five.

“We always say in Pakistan it wasn’t a health issue, but a political issue. After the military operation we now can reach every child,” Tarar said. “We are fully cognizant that interruption and eradication are zero sum games.”

Transition

The transition as polio is eradicated will be complex, and needs to be carefully managed, country specific and country led.

Polio surveillance systems can provide an important foundation, and are tremendous assets to health care systems, said Irene Koek, the deputy assistant administrator of global health at the United States Agency for International Development.

Some WHA event participants discussed how to redesign existing polio-focused programs to achieve other immunization goals. In Pakistan, for example, the government is already looking at how to transition polio efforts to routine immunization, and how to maintain surveillance.

Transparency will be key to managing this transition, said Koek. Countries need to know where resources are available, what they are paying for, who is funding what, and how much donor money is at risk of disappearing. That will likely mean relying on multiple funding streams to help keep assets in place and build on polio’s foundations, she said.

Countries and governments will also have to step up to fill funding gaps and maintain programs as the transition unfolds. One example of that challenge is now unfolding in Angola, which is transitioning away from polio efforts and also graduated from Gavi, the Vaccine Alliance, meaning they are no longer eligible for the same level of support.

“It’s a double burden to pass through,” said Miguel dos Santos Oliveira, the director of national public health at the ministry of health in Angola. The government has to ensure immunization coverage, which means retaining personnel at national, regional, local and community levels, and mobilizing capital to fill gaps and keep programs going, he said. The government is mobilizing domestic financing and has added a budget line around ensuring immunization coverage.

Civil society organizations will have a role to play in advocating to keep local governments and ministries on target, said John Lange, the United Nations Foundation's senior fellow for global health diplomacy.

“I hope NGOs and civil society internationally and locally will be engaged,” he said. “It’s important for broad global health to ensure the transition goes smoothly.”

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