Polio-free Pakistan: The Challenge of High-Risk Districts

"Polio eradication efforts globally have generated evidence on how to tackle a wide spectrum of geographical, ethnic, topographical, religious, and social challenges in different contexts. While these challenges are relevant to Pakistan,...distinct local challenges...require novel approaches."

After 15 months without a case of polio, Pakistan reported 14 new cases of wild poliovirus (WPV) as of August 23 2022. Pakistan's Polio Eradication Programme contained the spread, but the virus continues to exist and circulate through 6 high-risk districts in southern Khyber Pakhtunkhwa (KP). These areas have unique challenges in terms of insecurity, post-conflict rebuilding, administrative flux, and the Tochi River enabling the spread of WPV from Afghanistan. This briefing paper explores these challenges and proposes approaches to permanently interrupt the circulation of WPV in Pakistan.

The briefing opens with a discussion of Pakistan's polio programme, which is steered by periodic National Emergency Action Plans (NEAPs). The 2020 NEAP formulated new approaches that, for example, increased focus on communication to address community resistance and generate vaccine demand. While the solutions undertaken through NEAP 2020 worked throughout the country, they demonstrated sub-optimal effect in the southern KP context. NEAP 2021-2023 brought additional layers to the actions promulgated in NEAP 2020, but some challenges persist in southern KP, specifically. They include:

• Precarious lived experience of the local people: Disillusionment with governing institutions and a historically fractured relationship with the state can be traced to poor development indicators and multiple military operations that have led to displacement and unfulfilled promises for compensation due to damages. This context, along with the lack of trust from local people in the high-risk districts, and scepticism for any public sector intervention or campaign, increases guardedness for the polio programme's vaccination drives.
• Shifts in governance and changing authorities: Given the evolving security and political environment of the region, the local people have constantly been in a state of uncertainty. Their lived experiences drastically vary as the governance, political approach, and military actions change. Moreover, under these circumstances, the management of Pakistan's polio programme struggles to keep processes and monitoring aligned; for example, in 2012, local leaders placed a ban on polio vaccinations, demanding a moratorium on drone strikes.
• Instability in the region: The ramifications of local developments and international or regional interventions exacerbate challenges of security and accessibility in these high-risk districts. More than 70 polio workers - mostly in KP - have been killed in attacks by terror groups since 2012. The fickle security environment causes the door-to-door immunisation activities to be rushed, with teams not spending more than 15 minutes in an area due to lack of protection and time. This hasty approach and constant threat of an attack means minimum face time with parents or caregivers, resulting in the disruption of campaigns and missed children.

The following recommendations offer localised solutions while staying embedded in the priorities put forward by the Global Polio Eradication Initiative (GPEI)'s Polio Eradication Strategy 2022-2026:

1. Enhancing the quality of the ecosystem for vulnerable communities through engagement in super-high-risk union councils (SHRUCs):
   • Identify and establish champions at the grassroots such as tribal leaders, politicians, and activists. Leverage the stature and social capital of community leaders to mobilise more support for GPEI strategy vectors such as gender-sensitive ethnography, demography, and greater health system participation.
   • Incentivise vulnerable communities by improving public service delivery (in priority sectors other than immunisation). This entails motivating communities and local leaders to support unhindered polio vaccination campaigns and immunisation activities, so that "context-adapted community engagement" through "Community Immunization Committees" (as per the GPEI strategy) can become a reality.
   • Enhance trust within and with vulnerable communities in vaccine delivery by making local leaders partners in the process of vaccinating the children of their communities. Part of the larger demand-side improvement effort, this change to campaign operations may assist in restoring the trust of communities, elders, and local leaders in public service delivery instruments and touchpoints, thereby reducing refusals and resistance.
2. Making immunisation an integral part of wider negotiations with non-state actors:
   • Ensure that the facilitation of all polio and routine immunisation activities is a key element of the Pakistani state's demands during any negotiation processes with proscribed groups. The eventual agreement must have the input of Pakistani immunisation experts.
   • Leverage the Afghan Taliban's facilitative attitude for United Nations agencies' polio eradication efforts to generate greater regional and local political will. Security and access are paramount to polio eradication efforts and can be ensured through the inclusion of immunisation in the negotiation process.
3. Recalibrating the Polio Eradication Programme to increase worker motivation and improve mother and child health:
   • Engage the frontline force (polio workers and security personnel) by building and deepening understanding of the barriers to their performance and recognising and rewarding their efforts.
   • Enhance routine immunisation (RI) and maternal, newborn, and child health (MNCH) by using the impetus of polio to increase advocacy, operational mobilisation, and uptake for other health concerns, and consequently expand integration efforts and unified partnerships.
4. Leveraging technology to boost innovations in programme development, management, and monitoring and evaluation (M&E):
   • Conduct an extensive two-fold study to explore existing innovative technologies for tracking/tracing and their replicable use cases for Pakistan's polio eradication context. These innovations could lead to enhanced detection and response through sensitive surveillance technologies, improved access, and supplemented microplanning processes, thereby reaching every child.

In conclusion, strategies going forward in southern KP toward polio eradication include enhancing the public service ecosystem for vulnerable communities, making immunisation a priority point in Tehrik-i-Taliban Pakistan (TTP) negotiations, structurally recalibrating the polio eradication programme to increase worker motivations and synergise with other health interventions, and leveraging technologies for better access and microplanning.