The Global Polio Eradication Initiative is winding down. What are the risks?

CANBERRA — As global polio programs enter the final stages of eradication activities, with certification expected in the next three years, the Global Polio Eradication Initiative, or GPEI, is beginning the process of winding down its activities and will eventually cease to exist.

But a new report from RESULTS is warning about the gap this will leave — and they are urging donors and health organizations to begin planning now for how the current funds can be transferred to target other diseases and global immunization programs.

The report, A Balancing Act: risks and opportunities as polio and its funding disappears, identifies a range of gaps in the wind-down of the GPEI. This includes the risk of losing 70 percent of global funding for surveillance and 146 laboratories globally as part of the GPEI network (including 122 that are accredited members of the measles and rubella network). It also looks at the impact in four countries where GPEI funding accounts for more that 50 percent of World Health Organization staffing costs, and the potential collapse of immunization systems in developing countries.

GPEI has an annual budget of around $1 billion. Of this, 95 percent is spent in just 16 countries with funding now in decline and expected to stop by 2019.

“GPEI is a unique partnership and very different to the other health multilaterals,” Laura Kerr, the policy advocacy officer for child health with RESULTS UK, explained to Devex. “One of the strengths and weaknesses of the polio program has been its focus on a single disease. The GPEI only has a mandate and funding for polio eradication. There is no scope for it to continue and we need to move away from single disease initiatives if we are to make progress on globally agreed immunization and global health goals … particularly Sustainable Development Goal number three.”

For countries heavily reliant on GPEI funding, Kerr believes the worst-case scenario of a collapse in immunization systems is a possibility. “For the countries who currently do not appear to believe funding will actually end, there is a real risk they will be completely unprepared for the gaps which will be left,” she said. “Further, if funding ends before countries have costed and funded transition plans, alongside the political will to implement these and deliver on domestic resources, services which have been supported by GPEI will end.”

This could mean local communities could lose their sole immunization officer responsible for delivering a number of routine services — including implementing campaigns that deliver polio vaccines and vitamin A capsules together.

“There is a need for much more analysis to be done, beyond counting staff and contributions to polio and immunization budgets, to fully understand what the worst-case scenario will be,” Kerr said. “Based on the reduction in staff at the country level, organizational capacity, and support for key building blocks of an immunization system (such as surveillance) — there is little doubt that fragile and weak immunization and health systems will be disrupted, impacting the delivery of life-saving vaccines to some of the world’s most vulnerable children.”

How does a GPEI wind-down provide risk to wider immunization schemes?

According to the report from RESULTS, only 7 percent of children in the 73 poorest countries are fully immunized. The statistics are despite the fact that global immunization rates are higher than ever at 86 percent. This consists of up to three doses of diphtheria, tetanus, and pertussis, but does not reflect the number of children who miss out on critical vaccines that could prevent measles, pneumonia, meningitis, and diarrhea — the latter one of the biggest killers of infants.

“One in 10 children received no vaccines in 2016,” Kerr said. “This is unacceptable and urgently needs [to be] addressed.”

With vaccines extended, the lives of another 1.5 million children would be saved each year — on top of the 2 to 3 million lives vaccination currently save. But there are a number of challenges and barriers that countries often face.

Faced with changing health budgets and support from the wind-down of the GPEI, developing countries are seeing an increasing cost for full immunization. The introduction of new vaccines, necessary upgrading of systems and supply chains, training of staff, and costs of campaigns are all factors in increased costs.

These two factors — combined with weak and fragile health systems, a lack of data at a national and subnational level, and a lack of awareness of the benefits immunization programs — are putting immunization programs are at risk. But Kerr said there also needs to be greater political will for immunization programs.

“One of the most corrosive forces affecting the lack of progress in countries that have seen little or no progress is low commitment to immunization at all levels,” she said. “This has a considerable effect on the level of funding dedicated to immunization, and subsequently on service delivery. The hardest-to-reach areas, which require the greatest investment, are also often neglected by national health investment, further exacerbating physical resources for immunization.”

What action will RESULTS be taking?

Since 2011, both the Australian and U.K. governments have provided strong support for the GPEI — and RESULTS has been there to encourage and foster these relationships.

“In the last year, we have built cross-party groups of One Last Push champions, both in the U.K. and Australia,” Leila Stennett, campaigns director at RESULTS Australia, told Devex. “The Australian champions include Minister for Health Greg Hunt, Senator Claire Moore, and Andrew Broad MP, while U.K. champions include Kate Osamor MP and Jeremy Lefroy MP.”

The polio champions, Stennett said, have expressed a desire to not only see an end to new polio cases, but to ensure the sustainable eradication of polio — which requires a successful transition of GPEI resources into other health services. “We will work closely with the champions, the Department for International Development, and Department of Foreign Affairs and Trade to make the case for transition,” she said.

RESULTS will also be calling for a high-level meeting during the World Health Assembly in May 2018 to encourage top-down political attention to the GPEI and what happens next.

What should a wind-down or transition look like?

Stennett explained that now is a critical moment to leverage the historic impact of GPEI to ensure routine immunization is not lost. “Momentum towards polio eradication should be transferred to a broader agenda to improve access to life-saving vaccines for millions more children around the world,” she said.

But what would this transferred agenda look like and what would it mean for donors?

Kerr believes lessons should be learned from the past 30 years of GPEI and ongoing conversations around transition must ensure lessons learned are shared widely with global health stakeholders.

“The vertical and targeted approach is what has brought the world closer than ever to polio eradication, but the Independent Monitoring Board recognizes that heightened investment and focus on routine immunization could have had a positive impact, and even a ‘rocket boost,’ on eradication,” she said.

There is also a need to move away from single disease initiatives to focus on broader health gains.

“It is of critical importance that global efforts to eradication polio, including the appropriate assets and lessons, be transferred or transitioned into wider global health,” Kerr said. “And we believe there is a specific opportunity for routine immunization. This is not to create a new entity, but to refocus global efforts and resources on the need to strengthen routine immunization, a core building block for a primary health care system, and a critical step towards UHC [universal health care]. Routine immunization systems will need to deliver IPV for at least 10 years to ensure the world remains polio free.”

But currently, Kerr explained, donor awareness of the impact of GPEI wind-down is low. The conversation on future financing is not currently being discussed in detail or in public — which puts health funding at risk.

“At last year’s WHO Executive Board and World Health Assembly, donors put considerable pressure on WHO and GPEI to present more information on what the wind-down of GPEI means for polio, immunization, and global health, and what actions need to happen now to maintain services,” Kerr said. “Financing was not part of this.”

Key messages for governments, donors, and global health organizations

From the report, there are several key messages RESULTS hopes to communicate to key stakeholders who can influence the future of the GPEI and transition their work.

“For governments of developing countries, we recommend increasing domestic resources for immunization within a growing national health budget, and developing costed transition plans which consider likely reductions in GPEI and Gavi support,” Stennett said.

“For both developing countries and international supporters, we recommend a meeting of stakeholders at the World Health Assembly 2018 to explore the barriers, gaps, and challenges which urgently need to be addressed, not only to ensure a polio-free world, but also to ensure the unique opportunity to strengthen routine immunization is not missed.”

Bilateral donors are encouraged to use both influence and direct funding to support successful transitions to a new phase of health and immunization support. “Donors such as U.K. and Australia should use their positions on the boards of Gavi and many polio and GPEI technical working groups to highlight the opportunity to use GPEI wind-down to strengthen routine immunization programs, and provide technical and financial support to build capacity for transition planning and implementation,” Stennett said.

And she urges GPEI and Gavi to work together to improve coordination and transition planning at the country level. “Gavi should also continue support for the inactivated polio vaccine until 2030 to sustain polio eradication,” Stennett said.

NGOs are also encouraged to do their share in bringing awareness to the risks of an ad hoc GPEI wind-down.

“We can’t ignore the fact that the GPEI will be the largest health program ever to be wound down,” Stennett said. “Other NGOs or organizations should be highlighting the huge risks this creates to the sustainability of polio eradication. If resources currently allocated to polio campaigns are reduced and not replaced by domestic funding, this could mean we see the return of polio cases.”

“For countries who already have weak or under-resourced immunization systems, there’s a risk they won’t be able to mainstream polio essential functions into current health services,” she warned.

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