Catalyzing Health Gains through Global Polio Eradication: An India Trip Report

India is using tools developed for global polio eradication to increase broader immunisation rates, enhance disease surveillance, and improve health communication in under-served areas. To examine India's polio asset transition efforts, explore the role of the United States (US) government in the process, and highlight India's approach to polio transition as a potential model for other countries facing similar issues, the Center for Strategic & International Studies (CSIS) Global Health Policy Center sponsored a 5-member research delegation to the country in March 2016. This report emerging from that process suggests that India's polio programme's assets offer a unique, time-limited opportunity to create lasting health system improvements that will not only benefit Indians but also increase global health security. But careful, deliberate planning is required for this potential to be realised for the long term.

Since India eliminated polio from the country in March 2014, health officials have used polio programme strategies to provide services to hard-to-reach populations, taken on funding of the national polio laboratory network originally funded by the Global Polio Eradication Initiative (GPEI) and expanded its capabilities to include measles and rubella, and collaborated with polio programme partners - including US health agencies, the World Health Organization (WHO), and the United Nations Children's Fund (UNICEF) - to raise childhood immunisation rates.

The report shares several examples to support the claim that "India has long been at the forefront of polio transition efforts." For example, on the margins of society and frequently on the move, brick kiln children have been difficult to reach with immunisations and other health services. The GPEI, with its mandate to immunise every child with oral polio vaccine, designated brick kilns - along with construction sites, urban slums, and remote tribal settlements - as high-risk areas that required special attention. India's ability to successfully vaccinate children in those places was key to its success in eliminating polio. National and state governments along with international partners now are using the tools initiated by the polio programme, such as polio's social mobilisation and micro-planning techniques. Health workers use them to educate parents about the importance of immunisations and work with both them and the broader community to ensure that children receive the vaccines they require. Among the very few possessions of a woman at a brick kiln the delegation visited was her child's well-used immunisation card, an object she kept carefully wrapped in plastic to protect it in her dusty surroundings.

Looking in more depth at transitioning polio assets to immunisation and disease prevention activities, the report offers these case studies:

1. In April 2015, the government launched Mission Indradhanush (MI), a programme to raise the proportion of India's fully immunised children to 90 percent by 2020. MI used polio programme data to identify 201 high-focus districts with the largest number of unvaccinated and under-vaccinated children. They include populations living in urban slums with high migration levels, nomads, families working at brick kilns and construction sites, those living in remote areas such as forests or riverine nvironments, and areas short of regular health workers. MI uses other assets and strategies developed through the polio eradication programme including: personnel and strategies to immunise underserved and hard-to-reach populations; social mobilisation activities through mass media, mothers' meetings, engaging local leaders (religious, political, medical), and interpersonal communications to increase awareness of the value and availability of vaccines; intensive training of health officials and frontline workers to enhance the quality of immunisation services; and involvement of district task forces composed of government officials and health officers to ensure accountability and data review on a timely basis so that immunisation coverage gaps can be identified and addressed. Critical technical assistance and other polio partner participation in the project would be curtailed after 2019 without additional funding beyond that provided by the GPEI.
2. Established in 1997 by WHO, the National Polio Surveillance Project (NPSP) helps plan, administer, and oversee polio eradication activities in India. In addition to being an essential component of India's polio elimination drive, NPSP has served as a de facto public health training institute for the Indian health system. Many experts feel such an expansion should be strategically planned and evaluated in order to prevent overstretching the effectiveness and work quality of the institution.
3. Developed through UNICEF and CORE Group Polio Project, SMNet deploys more than 6,000 women from high-risk communities to talk with parents about their concerns about vaccination and to encourage them to immunise their children. It also holds education sessions with mothers to discuss immunisation as well as nutrition and hygiene, diarrhoea management, and to encourage exclusive breast-feeding. The SMNet organises media messages and creates networks of religious and other community leaders to urge vaccination. It is now using the same tools to create demand for routine immunisation. An independent assessment of the SMNet released in 2014 found the organisation to be effective in reducing polio vaccine refusal rates and reaching underserved communities with health messages and helping them connect with frontline health workers. UNICEF is in negotiations with national and state governments in India to take over the bulk of funding for the SMNet and is working with other development partners, including Gavi, to fill the funding gap. The Indian national government agreed in November 2015 to fund the network until 2018. Future need and funding will be determined by the states.

The delegation's observations and analysis led to the following recommendations:

• The US government should continue contributing both resources and technical expertise to India's polio programme at least through global certification of polio eradication, an event now anticipated for late 2019 at the earliest.
• The US government at all levels, and especially the US Mission to India, should continue and intensify its work with the government of India, international organisations, and other development partners beyond those supporting polio eradication to develop a comprehensive, long-term polio transition plan. The plan should, to the extent possible, secure polio assets permanently within the Indian health system rather than have them operate in short-term campaign mode and should expand the use of polio assets to issues beyond polio eradication. (An example of this is the MI programme described above.)
• The Indian polio transition plan should ensure continued progressive financial assumption of polio assets by the Indian government. The US government and other development partners should be prepared to fill in financing gaps at least for the short term to ensure continuation of valuable health tools and to enhance global health security.
• The US should examine Indian polio assets such as disease surveillance, laboratory capacity, social mobilisation networks, and outbreak response capabilities that support US health goals related to measles and rubella elimination, immunisation system strengthening, child health, and global health security and consider providing funding for those activities beyond global certification of polio eradication.
• The US and other development partners should support and encourage continued external monitoring for disease surveillance, data collection, communications, and immunisation activities to ensure efficient operations and accountability.
• The government of India should continue and intensify reforms that ensure adequate numbers of properly supported frontline health workers and functional health facilities.

In short, the delegation finds that, "[w]hile India's quick and effective use of polio assets has been a boon for health activities there, the Indian government's approach has been more fragmented than perhaps would have been ideal....The U.S. government should continue to be a strong partner to India as it develops strategies for a continued successful polio asset transition."