The drive to eradicate polio in Pakistan has recently been marked by four positive developments. First, acknowledgement by the government that the country now runs the risk of becoming the last remaining reservoir of endemic poliovirus transmission in the world. Second, the US $ 17 million direct pledge for polio eradication in Pakistan by the Bill and Melinda Gates Foundation, at a time when there is a severe fiscal crunch. Third, pronouncement of polio as a national emergency and the decision to leverage outreach of the armed forces in conflict-ridden areas—the latter being one of the hallmarks of the National Emergency Action Plan for Polio Eradication, 2011 (Plan). This was a long overdue policy decision, since problems in accessing children in war and conflict zones have been apparent for a long time.
Important as these decisions may be, there are additional considerations that should be brought to bear. The issue in conflict-ridden areas is not just a matter of constrained access due to the law and order situation. There are organized factions that campaign widely against polio vaccination, effectively orchestrating parental refusal to vaccinate children on the mistaken grounds that vaccination is forbidden by religion, that it causes infertility in populations and that it is part of a conspiratorial design against Muslims. Indoctrination of this philosophy has been one of the most important factors in undermining immunization activities in many parts of Khyber Pakhtoonkhwa (KP) and the tribal areas. Addressing this necessitates changing mindsets, which may not necessarily be amenable to short-term measures.
The cross-border movement of nomadic populations is often cited as one of the factors limiting success. To a certain extent, the combination of conflict, mindsets and movement of populations in the tribal areas and associated areas of KP are relevant. This is evidenced by numbers—in 2010, nearly three out of every four new cases of polio, were from these areas. This notwithstanding, it must be recognized that the sources of persistent transmission, or the 33 districts, which are high-risk and those that adjoin them, also include central Punjab and Karachi, which are far removed from the western borders.
It is evident that weaknesses in health service delivery and broader issues in health governance are responsible for the failure to eradicate polio. In fact, there has been an honest admission in the Plan that there is “sub-optimal quality of implementation and poor programme management” and that “inconsistent quality of polio campaigns stemming from weak management and political interference” is a problem.
The performance of field outreach teams falls on a spectrum and despite effort to reform primary healthcare, there are many units that are still non-functional. Abuse, pilferage, absenteeism, ghost workers, informal payments, outright graft and systematic collusion at several levels are pervasive, and in some cases, well-institutionalized. Capacity of the public primary healthcare system, which anchors the field immunization process, has been deeply eroded over the decades. Instances of deployment of managers without regard to merit do not augur well for programmatic functioning. The private sector, which delivers the bulk of healthcare, has not been leveraged for enhancing outreach.
Weaknesses in other government services can also affect polio-control efforts. Heavy electricity cuts due to load-shedding can have consequences for maintaining the cold chain for vaccine storage. As a result of issues at the level of water and sanitation, diarhoeal diseases—the third commonest cause of deaths in children in Pakistan—can interfere with polio vaccine absorption. The impact of these factors on results of the polio eradication initiative needs to be determined.
Furthermore, there are other more recent systemic changes-in-the-pipeline, which inadvertently act as barriers. Ongoing debates about reorganization of national programmes and how interventions such as immunization may be organized in the future—now that the Implementation Commission of the 18th Constitutional Amendment is set on devolving all health-related functions—is one of them. The other process in the flux is the local government system. Both these institutional changes are deeply interlinked with the fate of human resource actors within the system, the performance of which critically determines progress. For example, health administration is part of the recently envisaged massive job cuts at the local government level in one province. Uncertainty and low morale as a consequence thereof at the human resource level is detrimental to the needed rigour, which must come into play to achieve the goal of polio eradication. These factors are outside of the remit of the Plan.
This notwithstanding, the Plan itself, has to be more rigorous. Three points are being emphasized. First, emergency measures similar to those adopted during disasters and wars are required. The entire organizational force of the government needs to be put behind polio eradication, not only in the conflict-ridden zones but also in other areas. The armed forces need to be involved in the outreach drive in National Immunization Days, just as they are in other emergencies. The government should commit to utilizing all its resources to ensure a seamless supply chain over a few days including airlifting of vaccine and ensuring access to areas on horseback. The possible imposition of curfews for the duration of immunization days should be considered drawing on insights from the Chinese experience. An emergency has to be dealt with as such.
Secondly, there should be clarity in administrative responsibilities. The current ambiguity at the local government level and federal-provincial interface needs to be streamlined for the set of actions critical for delivery of services in this area. Additionally, more important than the elaborate inter-sectoral committees outlined in the Plan, is to clearly define the level which is to be held accountable. Thirdly, there should be an effort to somehow link polio eradication to the right to life, using quotes from the Quran in order to negotiate access in areas where refusal is an issue. With these measures, there could be some headway towards the goal of polio eradication in Pakistan.
One last word pertains to using polio as a lens to view the broader situation with regard to development outcomes. As a health systems intervention, immunization may be more transaction-intensive than certain health interventions such as food fortification, but it is not as transaction-intensive as others, for example, emergency obstetric care. Here is a jarring realization. If Pakistan is faltering to achieve an immunization-related end-point, how will it deal with the complexity of other interventions, which are critical to achieving targets such as the Millennium Development Goals, to which the country is wedded. Polio, therefore, also provides insights into the country’s wider institutional capacity and the ability of its systems to deliver on programmatic endpoints.
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