A Debt of Honour: Delivering Polio's Legacy for Those Who Have Suffered and Those Who Have Died

The Global Polio Eradication Programme (GPEI) created the Transition Independent Monitoring Board (TIMB) to monitor and guide the process of polio transition planning. This report, the TIMB's third (see Related Summaries, below), captures the TIMB's view of progress and prospects following a meeting (Supporting Polio Transition in Countries and Globally: A Shared Responsibility) convened by the World Health Organization (WHO) Polio Transition Team in Montreux, Switzerland, November 13-14 2018.

The report begins with some general reflections on the context in which the TIMB convened. For example, although the number of polio cases is low by historical standards, 2018 was not a good year - with the GPEI's IMB concluding in its 16th report (How to Cut a Long Story Short) that progress towards interrupting polio transmission globally has stalled and may well have reversed. In addition, far from worrying about the risks of moving too quickly with polio transition (when the poliovirus, in 2 of the endemic countries, seems to be gaining the upper hand), the tenor of the debate on polio transition has been one of frustration with the speed of progress.

The next section looks at the possibility of polio-funding-dependent countries becoming self-sufficient. It was announced at the Montreux meeting that the GPEI's Transition Management Group had been dissolved; beginning in July 2018, country planning was devolved to World Health Organization (WHO) and United Nations Children's Fund (UNICEF) regional country offices. TIMB is concerned that there is little information about the way they approach this both within and between the 2 organisations. Furthermore, the perception is that, on paper, transition plans may appear finalised and approved by the governments, but the challenge is that there are few funding sources other than the GPEI budget.

The TIMB examines the relationship between what is variously called "routine" or "essential" immunisation, polio eradication, and polio transition - a relationship TIMB calls complex, multifaceted, and, at times, contentious. The TIMB critically examines, for instance, the current Global Vaccine Action Plan, which has almost run its course and "has not really functioned as an effective plan" (although, as an advocacy document, it is said to have worked well). Work has already started to create a new Global Vaccine Action Plan. According to the TIMB, other very practical problems have impeded progress towards high routine immunisation coverage rates. For example, the engagement of local government and non-governmental entities is often very variable, yet the ownership and commitment at this level to high immunisation coverage is vital. The end stages of the polio eradication programme have shown how, in the economically poorest communities, the legitimacy of, and trust in, government is called into question and halts progress in getting results. "Much can be learned from this experience and applied to the routine immunisation context for the future. Leveraging other social and health programmes with immunisation can build goodwill and trust....At global level, facilitation, spreading of best practice, diffusing innovations and establishing and maintaining peer-to-peer networks, are just some of the things that WHO and the big partner agencies can do to add value."

The TIMB observes that, over a period of 30 years, a system of surveillance for vaccine-preventable diseases, including polio, has evolved based largely on a platform of polio resources. The news media tend to report on, and photograph or film, political leaders and celebrities administering polio drops, rather than showing them alongside frontline teams investigating children with paralysis. "As a result, in public visibility and understanding, polio surveillance has been the poor cousin of vaccination. It is important that this attitude does not come back to haunt polio eradication by undermining political commitment and ownership. In the pre- and post-certification periods, variable quality surveillance will wreck the eradication programme." The TIMB recommends strong awareness-raising initiatives at the national, regional, and global levels to ensure understanding of the essential functions of surveillance and the economic and security consequences of failed surveillance in order to ensure proper commitments and support.

Over time, the polio outbreak response is likely to move into a much broader emergency response platform at country, regional, and global levels: Poliovirus outbreaks would be managed like any other outbreak (e.g., cholera, Ebola). In practice, this will mean the transfer of responsibilities for managing poliovirus outbreaks from the GPEI to the WHO's Health Emergencies Team. TIMB stresses that this handover must be a carefully planned and articulated process, involving joint working and scenario planning over many months.

The TIMB looks at the process of establishing containment, which is underway. Within the WHO management structure, containment currently works in vertical programmes, where the pathogens are addressed in separate groups. TIMB suggests that all the groups could join together in one place where all various issues could be addressed, to the benefit of each individual vertical programme.

One notable announcement made at the Montreux meeting was that the GPEI has been extended from 2019 to 2023 - a decision clearly influenced by the ongoing battle with circulation of wild poliovirus (WPV) in the 3 endemic countries. It is clear that the GPEI will continue to directly manage the eradication process, but the TIMB argues that, going forward, a fundamental look at the governance of polio transition is essential. For example, "the communication so far has not made the programme's overall aim sound inspiring. Rather the opposite, it has mainly been about the important but dull tasks of reducing risks and finding money."

The TIMB stresses that the vision for polio transition cannot only be about what happens to the assets, people, and infrastructure; it must also be concerned with how to apply the lessons learned. A special task group of the GPEI has identified key areas of learning, such as harnessing global commitment to a cause, engaging and mobilising communities and influencers, fostering cross-border cooperation, and boosting gender empowerment. Some countries have commenced documenting their own lessons learned using a framework provided by WHO, and a Polio Transition Resource Library has been established. However, according to the TIMB, outside the "polio bubble" (and compared to polio eradication), polio transition is not well understood in the wider global health world - let alone by the public and media in Member States, nor by many government officials and political decision-makers. "For Polio Transition to be a success or, even better, reach its full potential, the widest possible awareness and engagement, especially of non-traditional polio organisations and individuals, is vital....The extent and quality of communication on Polio Transition so far has been very poor indeed. This needs to be remedied urgently."

In fact, TIMB suggests that "Communication and public information need a different approach....Every country, its leadership and its citizens, should have a very clear idea of what they have to do to ensure a polio-free world. That public consciousness should be a comprehensive one, that combines the commitment to end the game on polio, as well as the revalorisation of vaccines and strong support for surveillance as a means to sustain individual, collective and global health security. Such an approach to social communication will help many needed areas..."

The TIMB concludes by sharing an outline of next steps, including convening a series of 4 meetings to plan action in specific ares of the transition process, followed by a consultation with key polio stakeholders prior to the 2019 World Health Assembly to discuss future governance options. Finally, the TIMB provides a checklist of 20 actions in moving forward; to cite only a few: Design and build a major wider communications and resource mobilisation programme as a successor to the GPEI's Polio Advocacy and Communications Team (PACT) to explain and promote the purpose and goals of polio transition and assign clear responsibilities; establish policies and action to respond to the need for social support to disabilities and to recognise the suffering of polio victims, their families, and communities; and formally and publicly recognise the service given and lives lost by polio workers around the world. "This is a debt of honour."