Bolstering Public Health Capacities through Global Polio Eradication

"Despite the value of polio-funded assets to both the Ethiopian health system and U.S. global health goals, ensuring their continuation will involve challenging and complex planning and negotiations between the Ethiopian government and its health and development partners."

As the number of polio cases declines worldwide, the Global Health Policy Center (GHPC) at the Center for Strategic and International Studies (CSIS) has been focusing on the question of how to sustain useful public health assets now funded through the Global Polio Eradication Initiative (GPEI) - both in the United States (US) and in specific countries like Ethiopia. In that country, US-funded global polio eradication assets provide health services support, such as disease surveillance in hard-to-reach populations and social mobilisation that provides health education as well as alerting families to the availability of health services and encouraging their use. In addition to benefiting the Ethiopian population, polio programme assets contribute toward US global health goals; for example, immunisation system support is a priority both for the US Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC). The argument in this paper is that "[t]he U.S. government should be a proactive partner as the Ethiopian government begins making hard choices about which assets should be continued and how they should be paid for."

To provide context for the thinking behind the series of interviews a CSIS team conducted in Ethiopia in October and early November 2015 to understand polio resource transitions, the authors explore the history of the concept of a polio transition. The GPEI is encouraging countries to plan for polio resource transitions though a series of meetings at the WHO regional level and through consultative support, and the GPEI Transition Management Group has developed guidelines to help countries with the planning process. The GPEI is also urging international organisations not directly involved in polio eradication, such as Gavi, the Vaccine Alliance, to think through how polio-supported resources, such as personnel and cold chain capacity, might be used to support their programmes.

CSIS notes that Ethiopia, ranked 174th out of 188 in the human development index, struggles to provide health services especially to pastoralist/border areas. In addition to outbreaks of wild poliovirus disease, Ethiopia and other countries in the region have experienced cases of circulating vaccine-derived poliovirus (cVDPV), disease caused by the oral polio vaccine in areas with low population immunity and poor routine immunisation coverage. Complicating the provision of health services are high rates of malnutrition, low rates of health-seeking behaviour, and inadequate health infrastructure. The authors discuss US-funded polio programme resources, which are most highly concentrated in Ethiopia's border and pastoralist areas, and the organisations that provide them. For example, working through Ethiopia's Health Extension Workers, the CORE Group Polio Project provides training that promotes routine and polio vaccination through advocacy meetings, health education discussions, and social mobilisation activities. It also trained a cadre of nearly 8,000 health workers and community volunteers to conduct health education campaigns and contribute to community-based surveillance by monitoring for cases of paralysis, maternal and neonatal tetanus, and measles. A case study of CORE's work in the western border region of Benishangul-Gumuz shows how non-governmental organisations (NGOs) supported through US polio funding add health infrastructure to an under-developed region.

"Consultations with WHO [World Health Organization] and USAID staff involved with the polio program indicated that polio personnel and resources supported the Ethiopian government's infrastructure for disease surveillance and response, especially at the regional and local level. Polio resources are fully integrated into routine immunization and other public health programs and are providing valuable lessons to other programs in laboratory specimen transportation, integrated training, and supervision." Among the polio -funded assets described by interviewees as valuable are these examples: relationships with existing community structures, including local Ethiopian health workers for social mobilisation planning and campaign support for polio and routine immunisation; use of integrated personal digital assistant (PDA) checklists by WHO officers to monitor field activities and provide supervision for a range of immunisation activities; and success in establishing cross-border meetings and synchronisation. "These assets are at risk as program funding decreases."

Having discussed how polio-funded assets contribute toward priorities of the Ethiopian government as well as to those of the US, the authors note that ensuring these assets' continuation will involve "challenging and complex planning and negotiations between the Ethiopian government and its health and development partners." To assist, they provide a series of 8 recommendations, beginning with this one: Beyond physical assets, USAID and CDC should document lessons learned through polio eradication and disseminate innovations, such as approaches for reaching remote populations, to other heath activities. Further, US personnel should actively encourage other polio donors to become involved in transition planning. To cite another suggestion: Efforts should be made to keep the CORE Group Polio Project intact and expand its operations to other health activities, as it provides a successful coordination and supervisory model that is capable of identifying and responding to challenges in hard-to-reach areas.

The report concludes by urging the capitalisation of collaborations developed through the GPEI so as to: ensure that vital public health knowledge is properly retained and disseminated, bolster global immunisation rates, and improve global disease surveillance. The authors suggest that US government staff should support transition planning efforts in Ethiopia and elsewhere "as a way to fully leverage the substantial U.S. investments in global polio eradication and to further U.S. global health aspirations."