NAVIGATING COMPLEXITY - INDEPENDENT MONITORING BOARD - Global Polio Eradication Initiative
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JANUARY 2021
P OLIO TR AN S I T I O N
INDEPENDENT MONITORING BOARD
FOURTH REPORT
NAVIGATING
COMPLEXITY
Adapting to new challenges on the journey to a polio-free world
INDEPENDENT MONITORING BOARD
Members
POLIO TRANSITION
Sir Liam Donaldson, Former Chief
Medical Officer for England, Professor
of Public Health, London School of
Hygiene and Tropical Medicine, United
Kingdom.
Professor Sheila Leatherman, CBE,
Hon RCP, Professor of Global Health
Policy, Gillings School of Global Public
Health, University of North Carolina,
USA.
Dr Boluwatife Oluwafunmilola Lola-
Dare, President, Centre for Health
Sciences Training, Research and
Development CHESTRAD Global,
Nigeria.
Dr Senjuti Saha, Scientist, Child
Health Research Foundation (CHRF),
Bangladesh.
Independent status
The TIMB’s reports are entirely
independent. No drafts are shared
with WHO or other organisations
prior to finalisation.
2 NAVIGATING COMPLEXITY
content
BACKGROUND AND 04
OVERVIEW
REGIONAL AND COUNTRY 13
STATUS REPORTS
CRITICAL POLIO TRANSITION 21
FUNCTIONS
DATA INSIGHTS 40
ANALYSIS AND CONCLUSIONS 46
RECOMMENDED ACTIONS 71
FOURTH TIMB REPORT 3
BACKGROUND
AND OVERVIEW
The Transition Independent It is now convening under new terms
Monitoring Board (TIMB) was of reference matched to the Strategic
created in 2016 by the Global Polio Action Plan on Polio Transition 2018–
Eradication Programme (GPEI) to 2023 that was received by the 71st
monitor and guide the process of World Health Assembly in May of
polio transition planning. 2018. Under the new arrangements
the TIMB works closely with the
It has produced three reports, and Independent Monitoring Board (IMB)
this is the fourth. Following WHO that has been evaluating the process
taking over the leadership and of polio eradication since 2011.
management of polio transition
planning from the GPEI, the TIMB
was reconstituted.
4 NAVIGATING COMPLEXITY
TIMB MEETING IN NOVEMBER 2020
The new TIMB was due to have its Deputy Director-General. It heard
first formal meeting in July 2020. It presentations from WHO’s Polio
was asked to postpone this meeting Transition Team, and leaders of
until the autumn of 2020 because work programmes on essential
of the unprecedented pressure on immunisation; health emergencies;
WHO’s management team caused by global vaccine-preventable disease
the coronavirus pandemic. surveillance; and laboratory
containment and security.
It did hold a series of informal
discussions with the WHO Polio A wide range of delegations attended
Transition Team and polio stakeholders the meeting and participated in
during July 2020. This helped to discussions. They included donors,
gain an understanding of the state polio extended partners, UNICEF,
of polio transition planning as work Gavi (Global Alliance for Vaccines
in countries was about to resume and Immunisation), CDC (US
following the first wave of COVID-19. Centers for Disease Control and
Prevention), Rotary International,
The TIMB met between 3 and 5 the Bill & Melinda Gates Foundation,
November 2020. This report is and polio transition leads from the
based largely on the presentations Africa, South-East Asia, and Eastern
and discussions at that meeting. Mediterranean regional offices of
The meeting was opened by WHO’s WHO.
FOURTH TIMB REPORT 5
INTERFACE WITH 19TH IMB REPORT
ON POLIO ERADICATION
The IMB met shortly after this, and its 19th report (The World is Waiting) is now
available. It should be seen as a companion document to this TIMB report. To gain
a full understanding of the process of polio transition, including the current state
of polio eradication and the complexity of the polio-essential functions required to
deliver a polio-free world, it is necessary to read both reports.
6 NAVIGATING COMPLEXITY
HISTORY OF POLIO ASSETS
PROVIDING WIDER SERVICES
Over more than three decades, the GPEI has set
up infrastructure to pursue polio eradication in
countries around the world. This has supported
not only polio eradication-related activities, but
also functions that go well beyond this core
purpose, including: vaccine-preventable disease
surveillance with the laboratory functions;
essential immunisation activities; new vaccine
introductions in many countries; emergency
preparedness and response; and health system
strengthening.
In addition to these programmatic functions,
the GPEI has cross-subsidised the operations
support. Services such as logistics, data, finance,
human resources and administration are
essential to running the polio eradication work
but they, too, have become shared much more
widely.
Countries in a substantial part of the world,
particularly the Africa, Eastern Mediterranean
and South-East Asia Regions, have become
heavily reliant on the GPEI infrastructure to
sustain the broader public health functions.
Most of the support on the ground is provided
through the two, polio-eradication implementing,
United Nations agencies. In order to protect
these functions and ensure a smooth transition
to the countries’ governments, careful planning
is needed.
7
PREVIOUS TIMB EVALUATIONS OF
PROGRESS
The TIMB’s three previous reports on polio At that time, it was made clear that polio
transition planning were carried out whilst the eradication funding would not be available
GPEI was facilitating and overseeing the polio beyond the period of eradication to fund
transition planning process. polio assets that are subsidising other public
health services at country level. Also, the
GPEI signalled that it would be reducing
funding and in due course be dissolved as an
organisational entity.
A core purpose of polio transition became
shifting the functions and funding from the
Polio Programme to country governments and
national health programmes.
The certainty regarding termination of
funding required countries to undertake
the necessary planning towards retaining
polio assets through self-sufficiency (either
paying out of domestic budgets or mobilising
external donors). This process was initially
led by the GPEI Transition Management
Group using funded consultants to carry
out the detailed work resulting in each polio
transition country having a plan.
The TIMB had two principal concerns at
the end of the GPEI’s oversight of polio
transition planning. First, that many countries
were struggling with the reality of finding
sufficient funds for staff and public health
infrastructure. They had received these
resources from the GPEI, as a free good,
for decades. Second, progress described at
TIMB meetings was not consistent with what
informed observers were saying: that many
polio transition plans were largely statements
of intent and had not always engaged senior
ministry of health and United Nations agency
country staff.
At that point, leadership for polio transition
planning passed from the GPEI to WHO.
8 NAVIGATING COMPLEXITY
ADOPTION OF A FORMAL PLAN
FOR POLIO TRANSITION
A Strategic Action Plan on Polio Transition
2018–2023 was requested by the 70th World
Health Assembly in decision WHA70(9)
(2017) and noted by the 71st World Health
Assembly in 2018.
It has three key objectives:
1. To sustain a polio-free world after the
eradication of poliovirus;
2. To strengthen immunisation systems,
including surveillance for vaccine-
preventable diseases, to achieve the
goals of WHO’s Global Vaccine Action Plan
2011–2020;
3. To strengthen emergency preparedness,
detection and response capacity
in countries to fully implement the
International Health Regulations (2005).
These remain the three pillars of polio
transition planning.
At the policy-making level, the tenor of the
debate on polio transition was initially one
of frustration with the speed of progress.
This is reflected in some of the interventions
during the May 2018 World Health Assembly
discussions, for example, the European Union:
“Unless implementation of the polio
transition plan is accelerated, we foresee
a significant risk for global health security.
But time is running short. The WHO’s
efforts, hence, must be energised”.
FOURTH TIMB REPORT 9
THE MONTREUX STAKEHOLDERS’ MEETING:
NOVEMBER 2018
Following the World Health Assembly’s • There is a need for more high-level
adoption of the Strategic Action Plan on Polio political advocacy on the important
Transition 2018–2023 in May 2018, the next opportunity that transition offers for
step in the global coordination of the polio helping achieve broader global health
transition planning process was a meeting initiatives;
convened by WHO in Montreux, Switzerland • Transition support must take into account
on 13–14 November 2018 entitled the differences between countries’
Supporting Polio Transition in Countries and situations and capacities and keep a clear
Globally: A Shared Responsibility. focus on the country level;
• Funding to sustain polio assets remains
This important gathering was seen as being problematic for many fragile or low-
the first of a series of stakeholder meetings resource countries;
planned to guide polio transition; the • The extension of the GPEI (on account of
meeting’s objectives included: clarifying the slow progress towards polio eradication)
implications for polio transition of the new should not lead to reduced pace in the
5-year GPEI Strategy; identifying existing transition of polio assets;
and potential financing options for polio • In endemic countries, transition must not
transition; evaluating ways of achieving a detract from eradication, but concurrent
smooth transition; and discussing options for planning work can kick-start transition
governance of the polio transition and post- once polio is eradicated;
certification process. • Transition planning will not only
strengthen eradication efforts, but also
In-depth discussions took place on the contribute to strengthening health
four thematic priorities of polio transition: systems and emergency response
comprehensive vaccine-preventable disease capacity;
surveillance; outbreak emergency response; • Gavi is committed to working with
strengthening immunisation; and poliovirus eligible countries to determine and
containment. The meeting also explored potentially support immunisation-
options for future governance. essential functions at risk due to
decreasing polio budgets; assistance
The conclusions of the Montreux meeting would be through existing country-level
captured the consensus view of multiple resources, and time-limited to bridge to
stakeholders: more sustainable funding sources.
10 NAVIGATING COMPLEXITYWHO TAKES THE LEAD FOR
IMPLEMENTATION
Leadership and oversight of polio transition
are now being provided by a high-level Global
Polio Transition Steering Committee, chaired
by WHO’s Deputy Director-General. Regional
steering committees have also been formed
or reconvened to oversee polio transition
in the Africa, South-East Asia and Eastern
Mediterranean WHO regions.
Polio transition is a corporate priority for
WHO. There is much wider programmatic
involvement than before, in managing polio
transition activities within WHO across
the three levels of the organisation (global,
regional, country).
A corporate work plan defines roles and
responsibilities and includes activities to be
performed by the technical departments
across the three levels of the organisation.
It attributes responsibilities to the Office
of the Deputy Director-General, the Polio
Transition Team, the regional offices, and
departments at headquarters responsible
for work on polio eradication, immunisation
and health emergencies. These coordination
structures and functions aim to facilitate the
implementation of the Strategic Action Plan on
Polio Transition 2018–2023. has passed, the need for, and importance of,
involving other organisations and groups has
Whilst the WHO is the lead planning and become apparent.
implementing body for polio transition,
the successful delivery of the programme In May 2020, the World Health Assembly
can only be achieved through cohesive revisited polio transition planning and
partnership working. Key partners include received an update on implementing the
the spearheading polio-eradication partners strategic plan. A further progress report
(UNICEF, Gavi, Rotary International, the Bill & (EB148/23) will be provided to the 148th
Melinda Gates Foundation and CDC), donor session of the WHO Executive Board in mid-
countries and wider polio partners. As time January 2021.
FOURTH TIMB REPORT 11THE CONSTRAINTS AND OPPORTUNITIES
OF COVID-19
The countries’ polio transition plans were The COVID-19 work of the Polio Programme
all written before the COVID-19 pandemic has opened up insights and opportunities as
began. The pandemic has temporarily halted to how some of the goals of polio transition
the implementation of polio transition action. (e.g. integrated service delivery) can be
It has also had a negative impact on key achieved more rapidly or in new ways. This
disease prevention and control functions for so-called “silver lining” of the pandemic
polio and other vaccine-preventable diseases. is encouraging, but it needs to be viewed
In particular, surveillance and planned cautiously, given the potential for further
immunisation work have been hit hard. waves of the pandemic to be all-consuming of
Activities in some countries resumed in late staff time and resources.
July 2020.
For most of 2020, the normal process
Repurposed polio assets have played a vital, of detailed assessment of countries’
game-changing role in fighting the pandemic states of readiness and timetables for full
disease at national and subnational levels. implementation of polio transition has not
This has involved using polio staff, structures been possible because of the constraints of
and working methods, together with mapping COVID-19.
and information systems that are the
mainstay of polio eradication work.
12 NAVIGATING COMPLEXITYREGIONAL AND COUNTRY
STATUS REPORTS
Each country’s transition plan aims domestic funding. In some cases,
to define how the government will there is a need for external support.
integrate essential public health In fragile and conflict-affected
functions – supported until now by countries, this will have to be longer-
external funding – into its national term support. Almost all countries’
health programmes. The transition plans plans involve a phased approach, not
include mapping human resources and, an abrupt shift from GPEI funding to
where possible, matching and aligning government self-sufficiency. There
them to existing functions within the is a long-standing concern about
country’s national health priorities. the difficulty of transferring United
Nations field staff to government
The transition plans address how to contracts because of the salary
mobilise resources and to replace difference.
GPEI funding. In most cases, the ideal
approach is for the government to The polio transition process started
absorb these functions and provide with a list of 16 priority countries for
FOURTH TIMB REPORT 13polio transition: those where the Polio The commentary and analysis of
Programme has the largest footprint countries’ progress with their polio
(i.e. most staff and funding invested). transition plans in this section of
These countries are Afghanistan, the report reflects the limitations
Angola, Bangladesh, Cameroon, Chad, imposed by the pandemic. Country
Democratic Republic of the Congo, visits organised by the WHO
Ethiopia, India, Indonesia, Myanmar, headquarters Polio Transition Team
Nepal, Nigeria, Pakistan, Somalia, South could not take place. Nor could TIMB
Sudan and Sudan. members make their planned visits
to polio transition countries. Helpful
Four countries were subsequently information and judgements on
added to this list: Syria, Libya, Iraq and progress have been provided by each
Yemen. They were included primarily of the three WHO regional offices.
because they are fragile, or conflict- They have a major role in facilitating
affected, states. The funding and the further development of plans,
infrastructure provided to them by assessing progress and coordinating
the GPEI is not high, relative to the 16 implementation. The country position
priority countries, but does support statements in the sections that follow
critical areas and key functions. The are not standardised but reflect the
four are now part of the official list of different approaches that have been
polio transition countries, bringing the taken in the three regions.
total to 20.
14 NAVIGATING COMPLEXITYSOUTH-EAST ASIA REGION
The South-East Asia Region of WHO The polio transition plans remain
was certified polio-free in March at different stages of endorsement
2014. Of the 20 polio transition and implementation. So far, the
countries, five are in this region: countries have preferred that WHO
Bangladesh, India, Indonesia, should continue to manage and, in
Myanmar and Nepal. some cases, finance the integrated
networks, at least in the short- to
There are substantial polio medium-term.
eradication-funded assets supporting
both surveillance and immunisation India has a two-phase plan that
in each country. Systems have has been formally endorsed by the
evolved to underpin the other government. The first phase runs from
immunisation-related actions that 2018 to 2021, and the second from
have contributed towards measles 2022 to 2026.
and rubella elimination, maintained
surveillance for vaccine-preventable With the first phase coming to an end,
diseases, strengthened immunisation there has been a total transition under
systems, and provided support during a national plan called Polio to Public
emergencies and disasters in the Health. This enables the polio assets
region. now supporting polio surveillance, and
other activities related to maintenance
The polio assets have been highly of polio-free status, to become
valued by the countries. All five engaged with supporting measles
countries in the region have and rubella elimination, vaccine-
developed national plans. There is preventable disease surveillance,
a very strong commitment to polio new vaccine introduction and health
transition planning in this region, emergencies.
both from the highest levels of WHO
and in ministries of health. Ministries There has been a handover of
of finance are also engaged in the functions, using a state-based
process. approach. It is graded depending on
FOURTH TIMB REPORT 15the capacities of individual states in the with WHO. The assessment team especially after Gavi funding ends in
country. has recommended developing a risk 2021. COVID-19 may affect available
mitigation plan. funding, jeopardising the allocation of
There has been an emphasis on domestic resources to polio transition.
capacity-building within government Bangladesh has a plan that is fully
systems, so that there is no compromise endorsed by the national government. Myanmar has the goal that the
or loss of the gains that have been It started in 2016 and extends to 2026. government will take over after a
made. A key element has been the Implementation is happening in three successful period of capacity-building.
funding support from the government phases, with the first phase completed. There is a year-to-year transition road
to sustain these assets. A mid-term map. Subnational government positions
assessment has been carried out, Some of the milestones were delayed are being created to replace the regional
covering programmatic and non- towards the early part of 2020. surveillance officers. There are delays
programmatic areas (including human Surveillance and immunisation functions in filling these government posts. The
resources, operations and finance). The have been merged. The surveillance pandemic has also reduced the pace of
programme will be moving into phase activities are now budgeted in the polio transition. The mid-term financial
two from 2022 onwards. government’s operational plans, which sustainability remains a concern.
include laboratory functions, training
The key conclusion of the mid-term and outbreak response. Bangladesh has Myanmar has a very different
assessment was that polio transition relied on GPEI and Gavi funding in this organisational arrangement to those of
has significantly contributed to first phase. India, Bangladesh and Nepal, where field
strengthening the overall public health personnel are recruited by WHO. Field
systems in India. Phase two has been initiated. WHO staff are deputed to their roles from the
continues to manage the infrastructure. government on an annual basis.
The India Government’s commitment It will be funded through Gavi health
and vision, as well as the WHO’s system support as well as with Indonesia does not yet have a formally
leadership, has placed the polio government funds. endorsed government polio transition
infrastructure in a key role both plan. It has taken action to provide
nationally and subnationally. There has Phase three will run from 2023 onwards. funding and assume responsibility
been an increasing government financial This is when the plan intends that there for a number of polio programmatic
commitment, including support from should be a complete government functions. Indeed, WHO support in
the government of India to WHO for takeover of the infrastructure. Indonesia is limited to core technical
immunisation infrastructure. Thereafter, it will recruit and train new support at national and subnational
staff. levels. The GPEI- and WHO-supported
The gaps identified as a part of this costs are partially incorporated into the
mid-term assessment, include degrees Nepal has taken a two-phased approach. government budget. This includes the
of ownership varying between state The first is from 2017 to 2019 and the surveillance officers, polio-essential
governments and the lack of direct second, from 2020 to 2024. facilities and polio laboratories.
interface between the administration
and the finance teams of the Ministry of The country is adopting a system of Indonesia is considered low-risk
Health and WHO. federalisation. This has led to a delay for polio transition planning, but,
in the government’s endorsement of programmatically, there are performance
The review recommended joint work to its polio transition plan. Immunisation concerns. It is a large country and
develop a transition road map adapted activities are fully integrated in Nepal. the immunisation and surveillance
to the subnational level. The Ministry performance are weaker than in some
of Health was urged to encourage the The current funding sources remain the of the other polio transition countries.
state governments to fully engage in GPEI and Gavi (mostly the health system There has been surge capacity for the
the transition process and also have a strengthening stream). There are risks to vaccine-derived poliovirus outbreak
point person to support polio transition mid- and longer-term funding in Nepal, response.
16 NAVIGATING COMPLEXITYEASTERN MEDITERRANEAN REGION
The Eastern Mediterranean Region The GPEI policy is that the polio-endemic
is the only region of the world yet to countries of Pakistan and Afghanistan
eradicate polio; there are two endemic must focus on eradication and not embark
countries: Afghanistan and Pakistan. on a transition programme, though some
Over the last decade, the polio polio vaccine is delivered as part of
eradication initiative has provided over essential immunisation arrangements. A
$2.8 billion to the region. The majority full analysis of the polio situation in these
of this funding (80%) has gone to the two countries is in the 19th IMB report.
endemic countries.
The conditions in Yemen currently
The region is characterised by many militate against both ongoing polio-
acute and protracted humanitarian related operations as well as planning
emergencies. The unmet medical needs for transition. There are no GPEI-
of refugees and displaced persons funded polio staff. The polio team
greatly increases pressures on already lead has been absorbed by the WHO
weak health systems. The existence of essential immunisation function. Funds
both humanitarian crises and fragile are provided by the GPEI to support
governments inevitably delays polio surveillance costs, including government
transition planning. field staff and health professionals who
report acute flaccid paralysis cases.
There are eight priority countries. Four
were in the 2018 definition of priority There are huge delays in surveillance,
countries: the two endemic countries and response campaigns are extremely
– Afghanistan and Pakistan – plus difficult to mount. Over the past two
Somalia and Sudan. The four countries years, no campaign has been conducted
added to the list of priority countries for in the north, where the vaccine-derived
polio transition are Yemen, Iraq, Libya poliovirus outbreak originated.
and Syria and many of the others are
suffering from governmental instability, In Syria, there is a small polio team at
conflict and/or major humanitarian the national level. There are also a few
emergencies. surveillance staff at the subnational level,
FOURTH TIMB REPORT 17employed on a contractual basis. funded field staff at subnational level 4.5 million people at risk of vector-
Their salaries are shared with the were absorbed into the government borne diseases.
health emergencies function of the structure. This means polio The polio footprint in Sudan is
WHO regional office. They do work surveillance has been taken over by medium sized: there are 18 states and
for both polio and health emergencies the government. There is a polio team almost one polio field staff member
programmes. at the national level, but it is hoped per state. The health emergencies
that this team may be absorbed by the team has few people on the ground
Although Syria is extremely insecure, WHO Health Emergencies Programme and relies on polio staff to detect and
the government has expressed or the WHO Essential Programme on respond to outbreaks and provide
willingness to absorb core polio Immunization. technical support. The same staff are
functions. The GPEI is not confident used in training to support essential
that there is sufficient government Iraq has a relatively strong health immunisation strengthening. Sudan
capacity currently. However, it is system with a health facility in every views its polio staff as general public
possible that these functions could be district, resulting in a comparatively health officers. So, informally, there
absorbed into the Health Emergencies robust immunisation programme. has been an integration of sorts, but
Programme, as the two programmes formally there has not. This means
already work very closely together. Iraq’s polio team has not provided that polio staff are providing functions
significant support to essential that go beyond the terms of their
There has been no Polio Transition immunisation strengthening or contracts.
Team country visit to Syria yet, emergency outbreak response. Polio
so once the COVID-19 situation staff did not contribute greatly to Somalia is probably the most fragile
improves, these discussions can the COVID-19 pandemic, as there polio transition country in the region,
get underway. The polio team are no longer any field staff at the excluding the two polio-endemic
has provided support during the subnational level. The surveillance countries. It has the largest number
COVID-19 outbreak, and WHO polio indicators have deteriorated since of polio-eradication funded staff,
teams are in discussion with the WHO COVID-19, as they have in all other who work closely with the large
Health Emergencies Programme at countries. However, Iraq is the only numbers of WHO Health Emergencies
headquarters level to help cover costs country in the region that dealt with Programme staff. UNICEF is also a
for up to six months. COVID-19 whilst it simultaneously key partner in funding some polio
reduced its field staff presence at positions and the CORE group of non-
Libya is one of the more complex subnational level. The regional office governmental organisations (NGOs)
conflicts in the region. There are no polio team is in the midst of assessing has a small team too.
GPEI human resources in place. One the quality of the government
international position was abolished surveillance system. It wishes to The WHO and other health agencies
and the functions were transferred to investigate whether the reduction are currently running the health
two national positions. These have not in polio field staff had any negative system of Somalia. There is a very
yet been appointed; because of this, effect, or if deterioration was solely small WHO immunisation department
Libya has been described as “already due to COVID-19. and a poorly performing essential
transitioned.” Technically, this may be immunisation system. The polio
so but the country’s health systems Sudan is suffering from multiple crises. infrastructure contributes significantly
are very weak. It is essential to ensure There is a vaccine-derived poliovirus to other national health priorities.
that surveillance continues and outbreak that has led to surge-hiring There is huge reliance on the polio
also that the national immunisation of WHO polio consultants. There network across Somalia for public
programme is strengthened. There are is no current prospect of reducing health service delivery, particularly
vaccine-derived poliovirus outbreaks polio staff. There is also a weak outbreak response and vaccine-
in surrounding parts of the region that essential immunisation system, with preventable disease surveillance.
are a threat to Libya. approximately 13 different vaccine- There are ongoing vaccine-derived
preventable outbreaks, including poliovirus outbreaks. Transitioning
Iraq has begun its transition. In early diphtheria and measles. There are also assets and staff to the government is
2020, the WHO polio-eradication floods which have put approximately inconceivable at this point in time.
18 NAVIGATING COMPLEXITYAFRICA REGION
The Africa Region was certified free of The combined effect of COVID-19
wild poliovirus in August 2020. There and large vaccine-derived poliovirus
are seven polio transition countries in outbreaks on all polio transition
the Africa Region: Angola, Cameroon, countries in the Africa Region is
Chad, Democratic Republic of the very serious. This emphasises the
Congo, Ethiopia, Nigeria and South fragility of the health systems in these
Sudan. Six of these countries have countries and adds a sombre note to
developed costed national polio the good news that the Africa Region
transition plans. The plans have not was certified free of wild poliovirus in
been fully implemented because of August 2020.
lack of funding. It was hoped that this
would change from 2020, but with There was hope that, from 2020,
the COVID-19 pandemic, additional money would be put into polio
funding for polio transition plans is no transition plans. Most of the countries
longer possible. have said that they do not have the
money to do so. Their immediate
Most of WHO’s polio staff are in the focus is on tackling COVID-19 and
Africa Region. So, there is a heavy maintaining existing government-
dependence by public health services funded essential services.
on the polio funding. Also, this is the
region that has been most affected Angola was among the first of the
by circulating vaccine-derived polio countries in the Africa Region to begin
outbreaks in recent years. This has had the ramp-down in polio funding. It fell
a big impact on progress with polio by 40% between 2017 and 2020; this
transition planning. translated to a 60% staff reduction.
FOURTH TIMB REPORT 19The country’s priority has been to 2020, translating to 23% fewer staff. Health Initiative in 2017 as a national
maintain the gains of stopping wild The staff reduction was deferred until strategy to improve access to essential
poliovirus circulation whilst, at the same 2020 because of the risk of cross-border health services. It aims to standardise
time, supporting essential immunisation wild poliovirus spread from (then) polio- the package of community health
and responding to health emergencies. endemic Nigeria. This country is also services, to strengthen links between
dealing with extensive vaccine-derived communities and primary health
The government has started to poliovirus and with serious economic facilities, and to improve community
implement polio transition with difficulties, so earlier optimism about its ownership and governance of health
support from Gavi and a loan from the polio transition prospects has dissipated. services. It is intended to replace and
World Bank. There were difficulties in A realistic assessment is necessary of harmonise the delivery of fragmented
transferring WHO staff onto Ministry of the budget required and its resource community health services supported
Health contracts because of the salary mobilisation prospects. by NGOs with funding from different
differences. However, it was essential donors.
to retain these skilled staff, not least Democratic Republic of the Congo has
because Angola had a huge vaccine- been faced with large GPEI budgetary Under this plan, polio transition would
derived poliovirus outbreak in 2019 (81%) and staff (47%) reductions be embedded within this wider vision of
whilst, in 2020, it had to cope with between 2017 and 2020. The country health system strengthening. However,
COVID-19. has experienced prolonged vaccine- South Sudan is a fragile state with no
derived poliovirus outbreaks since early prospect of government funding.
There has been an active planning 2017. It has also been hit by outbreaks WHO’s regional office has provided
approach in Angola, but it has of Ebola, measles, cholera and other technical support with the national plan
been hampered by five changes of diseases. A mission was planned for the through a cross-cluster mission in 2019
government. As a result, the team second half of 2020, to look again at and another is planned for 2021.
leading the polio transition process has this complex situation but it has been
had to go back each time and explain it delayed because of the COVID-19 travel Nigeria has had the biggest polio
to a different set of policy-makers. restrictions. infrastructure in the Africa Region.
The country has a clear vision and sees
In Cameroon, there was an 85% GPEI In Ethiopia, where there has been a 70% polio transition within the context of
budget reduction between 2017 and GPEI funding reduction as well as a 43% developing primary care. The GPEI
2020, but staff reductions were not staff reduction between 2017 and 2020, budget has been reduced by 81% from
started because of the risk of cross- the government’s polio transition plan is 2017 to 2020. In 2020 alone, 11 polio
border spread of wild poliovirus when under review by the national team there. positions have been abolished in the
Nigeria was still a polio-endemic Outside technical support is needed but country.
country. The reductions did begin in this has not been possible because of
2020. The budgetary needs of the the COVID-19 pandemic. The country Rather than moving ahead with polio
government’s plan are unrealistic since continues to experience vaccine-derived transition planning and costing, the
they are pitched at a level in excess of poliovirus and measles outbreaks and government developed a business
previous GPEI funding. This is being other public health emergencies. case which can be used to mobilise
addressed in discussion with WHO’s resources. The WHO regional
regional office. South Sudan has experienced a 75% office and other agencies provided
GPEI funding reduction between technical support for this cross-cutting
Chad has experienced an 80% GPEI 2017 and 2020. The government investment case.
budget reduction between 2017 and of South Sudan launched the Boma
20 NAVIGATING COMPLEXITYCRITICAL POLIO
TRANSITION FUNCTIONS
WHO works through teams in its essential immunisation and health
headquarters, regional offices and emergencies, have key roles and
country offices to plan, deliver, responsibilities in aspects of polio
strengthen and improve a range of transition. It is not, though, their sole
technical functions that are critical purpose and they have key objectives
to meeting the objectives of polio and programmes of work of their own
transition. In this endeavour, WHO that are vital to global health and
works with the organisations that global health security.
have been part of the polio eradication
initiative, as well as an extensive group The TIMB heard from the teams
of partners with connections to each leading these programmes about
technical area. their contributions to polio transition
planning and implementation, as well
The technical programmes, in particular, as their wider programmes of work.
FOURTH TIMB REPORT 21ESSENTIAL IMMUNISATION AND POLIO
There are three key considerations
to achieving success for the essential
immunisation component of polio
transition planning:
• The first is to understand
why strengthening essential
immunisation is so vital to
reaching and sustaining polio
eradication;
• The second is to find the best
approach to integrating polio
eradication and essential
immunisation activities;
• The third is to ensure that polio
assets, experience and methods
of working can be successfully
absorbed into the global
immunisation plan for the coming
decade: Immunization Agenda
2030: A Global Strategy to Leave
No One Behind.
For most of the polio-eradication era,
the Polio Programme and essential
immunisation activities have co-
existed. There has always been a
degree of tension between the two
approaches.
Polio eradication is a highly-focused,
vertical programme pursuing one
disease, with a large, dedicated
continuous flow of funding and its
own workforce. It has been delivering
22 NAVIGATING COMPLEXITYa single vaccine, predominantly via fear that transition would distract and those countries with outbreaks
campaigns, many of which have from finishing the job on eradication, of vaccine-derived poliovirus are
been run door to door to try to reach using a vertical, campaign-style many of the same places that are
every child. This way of working has approach. susceptible to measles outbreaks.
suited the logistics of delivering an The occurrence of either is a
oral vaccine to the same children Unfortunately, over the last few sign of serious weakness in the
multiple times in a year. The years, polio eradication has run immunisation programme. They
outreach model has also fitted into serious trouble, with growing should be regarded as “canaries in
with the need to track down and numbers of wild poliovirus cases the coal mine” for where programme
vaccinate missed children and those in Pakistan and Afghanistan (the strengthening is needed, not just
in isolated or migrant communities last two endemic countries) and through outreach campaigns
that may not have access to other outbreaks of vaccine-derived but through better essential
public health services. poliovirus affecting more than 20 immunisation services.
countries. The paralytic effects of the
Routine immunisation (the vaccine-derived virus strain mean Ten countries account for a little over
preferred term now is “essential that it is wild poliovirus in all but 60% of all unprotected children (i.e.
immunisation”) has sought to prevent name. those who are not fully immunised).
and control a range of vaccine- Reaching every last child is a key
preventable diseases through a There are many reasons for Polio Programme target. Reaching
broader, more developmental and the current situation in polio all “zero-dose” children (i.e. those
longer-term approach with more eradication. They are discussed children who do not even get a
complex funding arrangements; also, fully in the 17th, 18th, and 19th single dose of vaccine through the
it has been playing a wider role in IMB reports. The serious outbreaks routine services) is the language
helping to strengthen primary health of vaccine-derived poliovirus used by the Essential Programme on
services. have been strongly associated Immunization to express one of its
with low essential immunisation key goals. These goals are really two
Whilst some had long advocated coverage. Strengthening essential sides of the same coin.
a more integrated approach in immunisation has become a critical
which polio was embedded within a element in reaching and sustaining The countries in the top ten are
broader programme of immunisation, polio eradication. so-called because either they have
the leadership of the GPEI very large birth cohorts and/or they
maintained that was a slower and When levels of essential have low vaccination coverage. For
less certain path to eradication. immunisation coverage are examined example, although India actually has
geographically, it is quite clear high vaccination coverage, it still
This attitude began to change with that polio is circulating in low- shows up in the top 10 of under-
the reversal of progress in polio immunisation coverage areas. There immunised children, because of the
eradication, particularly in Pakistan is also circulation in countries that size of the birth cohort.
and Afghanistan. have higher coverage, but almost
all is in subnational areas with low In order to reach both goals of
In earlier TIMB meetings, some coverage for polio vaccine. These are the polio eradication programme
stakeholders made repeated the areas within a country that are – stopping circulation of the wild
warnings that transition must not go at risk of vaccine-derived poliovirus poliovirus and shutting down
too fast. It was asserted that polio outbreaks. outbreaks of vaccine-derived
eradication had to be ahead of polio poliovirus – there has to be high
transition. This was because of the The wild poliovirus endemic areas population immunity against
FOURTH TIMB REPORT 23polio. Up until now, house-to-house
polio vaccination campaigns have been
a key method to enhance facilities-
based immunisation in order to increase
population immunity, especially in countries
that have weak or fragile health systems. It
is also how measles immunisation coverage
is being sustained in some geographies.
In the move towards polio eradication, the
delivery of both polio vaccines (eventually
only through the routine platform) needs to
be the mainstay of how immunity against
polio is achieved; this is because it also
creates immunity against other antigens.
Inactivated polio vaccine coverage is rising
very substantially, but it has still not reached
the coverage of even the most basic
measure of the strength of the Essential
Programme on Immunization. In all, 126
countries have successfully introduced
inactivated polio vaccine into their routine
schedules.
Whilst coverage is increasing, there are still
missed cohorts because of supply shortages.
This accounts for 22 million children in 23
countries. The process of introducing a
second dose of inactivated polio vaccine
will be scaled up in 2021, targeting 94
countries; of these, 32 have already
introduced it. Although Gavi is supporting
rapid introduction, there are likely to be
COVID-19 constraints on what would
otherwise have happened.
24 NAVIGATING COMPLEXITYINTEGRATING POLIO INTO
BROADER SERVICE DELIVERY
Greater systematic integration of the challenge of the current context
vaccine delivery can bring cost of the COVID-19 pandemic. It also
efficiencies and personnel efficiencies has the broader purpose of enhancing
but, most importantly, efficiencies and improving both the immunisation
for families that are currently programme and the specific polio
receiving services for more than one goals.
intervention at a time.
The interim Programme of Work for
The symbolic message is child- Integrated Actions is a structured
centred: the child should be seen as approach to thinking about exactly
a whole person and not just a polio how to develop integration further. It
vaccine recipient or a measles vaccine has four strategic areas:
recipient. An integrated vaccine
programme that is well organised can • Comprehensive vaccine-
also give clarity to families so that they preventable disease surveillance;
know what they expect to receive • Community engagement and
when they come for services. service delivery;
• Acute outbreaks;
The WHO is leading an interim • Management and coordination.
Programme of Work for Integrated
Actions that aims to accelerate the Focusing on technical and
alignment and coordination of key programmatic integration, each area
partner agencies that work on polio has been assessed according to its
and immunisation. It is identifying immediacy (Could it address current
actions that will be required to meet and critical programmatic needs?), the
FOURTH TIMB REPORT 25opportunities (Are there potential that require coordination with other common framework for decision-
synergies across programmatic health programmes, for example, making for mass vaccination
priorities?), and feasibility (Are there the Health Emergencies Programme, campaigns so that the risks and
implementation steps that could be WaSH (Water, Sanitation and Health), the benefits can be evaluated and
identified now?). and nutrition. inform the nature of the specific
integration activities. The elements
For each technical programme The interim Programme of Work for to be considered when assessing
area – comprehensive surveillance, Integrated Actions is also intended where the biggest gains can be made
community engagement and service to provide a “proof of concept” and on integrated activities are extensive
delivery, and acute outbreaks – the inform the further mainstreaming and include epidemiological patterns,
interim Programme of Work for of integration into the revision and health worker capacity, training,
Integrated Actions summarises the operationalisation of both GPEI supply chains and logistics, as well as
pre-COVID-19 status of integration, and broader essential immunisation communication strategies.
the new opportunities that are strategic plans.
provided in the context of the Whilst most discussion on integration
pandemic, and the specific proposed Integration is not an end in itself. It has focused on bringing together
actions. needs to be seen as something that the polio and essential immunisation
adds value to the quality, efficiency programmes, recent WHO polio
The management and coordination and community value of services transition work has also promoted
functions are the critical enabling delivered. There will always be trade- the wider adoption of “public health
factor. Overall changes are offs. There will be risks being balanced teams”. This approach will install
proposed for oversight, operational against the potential benefits. For within WHO country offices single
management, advocacy and resource example, will an integrated model teams with accountability for the
mobilisation. The focus is on of delivery reduce the quality of combined functions of polio, disease
integration of actions that are required campaigns or the intended size of surveillance, outbreak preparedness,
within the immunisation community – population coverage? detection and response, and essential
the GPEI and the Essential Programme immunisation. It is already a form
on Immunization – and also on As integration opportunities are of integration operational in some
integrated service delivery aspects sought, there will need to be a countries.
26 NAVIGATING COMPLEXITYA NEW 10-YEAR GLOBAL
IMMUNISATION STRATEGY
For the next decade, Immunization
Agenda 2030: A Global Strategy to
Leave No One Behind has been created.
Its vision is a world where everyone,
everywhere, at every age, benefits
fully from vaccines for good health and
well-being.
It has seven strategic priorities that
start with immunisation programmes
for primary health care and universal
health coverage. The other six
priorities comprise commitment and
demand; coverage and equity; life-
course and integration; outbreaks and
emergencies; supply and sustainability;
and research and innovation. There are
four core principles – people-centred,
country-owned, partnership-based,
and data-guided – that inform each of
the seven strategic priorities. Polio is
embedded in this Immunization Agenda
2030 vision and strategy.
There is a monitoring and evaluation
framework requiring global
measurement of three impact goals:
saving lives; controlling, eliminating
and eradicating vaccine-preventable
diseases; and reducing outbreaks of
such diseases. One of the proposed
indicators will assess progress on the
goal to control, eliminate and eradicate
vaccine-preventable diseases. Targets
FOURTH TIMB REPORT 27will be based on updated regional and 2011–2020 did report through the
global commitments. Clearly, since polio World Health Assembly and WHO’s
has a global target, this is how it will regional committees. This is still essential
be embedded in the monitoring and for the new plan, but responses to the
evaluation framework. consultation on Immunization Agenda
2030 pushed very strongly for building
The Immunization Agenda 2030 is seeking ownership beyond WHO processes;
to put right a serious limitation of the the idea is to pull all the partners and
Global Vaccine Action Plan 2011–2020. different agencies into the ownership and
The earlier plan did not have a sufficiently accountability framework. Consultees
strong ownership and accountability also argued for very strong coordination.
mechanism to drive action and results.
For the Immunization Agenda 2030, a There are three major plans that will need
great deal of thinking has gone into how to be closely aligned and feed into the
to secure meaningful ownership and processes of integrating, strengthening,
accountability through the lifetime of the and securing the benefits of
plan. immunisation. They are: (i) Immunization
Agenda 2030, (ii) a new GPEI strategy
Accountability frameworks will be that will be published soon, and (iii) the
needed at all levels, not just at the fifth phase of Gavi’s strategy covering
global level and not just at country 2021–2025 (often referred to as Gavi
level. The Global Vaccine Action Plan 5.0).
28 NAVIGATING COMPLEXITYHEALTH EMERGENCIES AND POLIO
OUTBREAKS
The Thirteenth General Programme of When there is no longer dedicated
Work 2019 –2023 defines WHO’s GPEI-led capacity, vaccine-derived
strategy for a five-year period and links polio outbreaks responses will be led
to three targets related to universal by health emergencies teams. Thus,
health coverage, promoting health and the health emergencies function,
well-being, and protecting people from through managing future polio events, is
health emergencies. essential to creating a polio-free world,
and is the last of the three pillars in the
The scope of WHO’s work in protecting Strategic Action Plan on Polio Transition
people from health emergencies is to: 2018 –2023.
• Prepare for emergencies by
identifying, mitigating and The aim is to strengthen country
managing risks; emergency preparedness capacities
• Prevent emergencies and support over time, especially those of vulnerable
the development of tools necessary or low-resource countries. This includes
during outbreaks; ensuring adequate surveillance systems,
• Detect and respond to acute health emergency event management, risk
emergencies; assessments, assessing workforce levels
• Support delivery of essential health and testing of the readiness of their
services in fragile settings. health systems.
FOURTH TIMB REPORT 29A key area is to establish an evidence-
based approach for identifying
and managing potential epidemic
and pandemic threats. As might be
expected, there is now a whole strand
of work prompted by COVID-19
covering accelerated research,
development and innovation. Other
work in this area is concerned with
scaling up existing strategies (in
particular, immunisation strategies) for
yellow fever, cholera, meningitis, and
with mitigating the risk of emergence
and re-emergence of high-threat
infectious pathogens (this work
includes biosafety and biosecurity).
On the operational side of health
emergencies, it is essential that
they are both rapidly detected and COVID-19 and was used in the of health emergencies will eventually
responded to. Key functions come Ebola outbreaks in West Africa and encompass the emergency response
into play here: epidemiological Democratic Republic of the Congo. capability for polio events. That was
surveillance; early-warning risk Work is also carried out to organise the original idea of including health
assessment teams; and scanning the provision of essential health emergencies in the polio transition
for, verifying, risk assessing, and services in fragile, conflict, vulnerable planning process.
monitoring all new events. and humanitarian settings when there
are protracted health crises; recent Whilst outbreaks of vaccine-derived
There is an Acute Event Management examples are in Syria and Yemen. poliovirus are still being managed
Unit in WHO headquarters which by the GPEI, the WHO Health
scales up operational and health A basic principle is that the generic Emergencies Team has been working
technical operations in an emergency. expertise in the management of with the polio team to integrate their
This enables the rapid set up of outbreaks rests within the health approaches. This has included the use
incident management teams; the emergencies function in WHO, of the emergency operations centres,
production of a strategic response and with the need for specialist teams – the emergency grading processes, the
operational plans; swift deployment whether it is polio, meningitis, cholera, emergency response framework, and
of an emergency workforce; securing Ebola or other serious outbreaks of the emergency standard operating
supplies; and coordination across disease – to be there to provide the procedures. Thus, there is a clear and
partners. This has happened for necessary technical advice. The scope comprehensive set of guidelines as
30 NAVIGATING COMPLEXITYto how WHO works in emergency tracing or isolation, has provided
settings. Also, joint risk assessments important learning for future polio
have been carried out with the polio emergency joint working.
team. However, because there is still a
strong Polio Programme, and a higher WHO’s COVID-19 Strategic
than expected level of vaccine-derived Preparedness and Response Plan
polio events, the core management of identified the need for $1.7 billion for
these health emergencies has stayed nine months in 2020. Around $1.5
with the GPEI polio teams. billion in funding was raised, 90% of
which went to regions and countries.
Meantime, polio expertise is being Under that plan, the pandemic-related
built up or strengthened within the work of polio teams (3,700 staff) cost
Acute Event Management Unit. Some around $60 million.
former polio staff have been hired
to work on emergency responses The COVID-19 experience has helped
at global, regional and country to consolidate thinking about more
levels. When the time comes for the integrated public health teams, which
Health Emergencies Team to take are able to do disease surveillance,
responsibility for acute polio events, outbreak preparedness, detection and
some management capacity will response, as well as immunisation. It
already be in place. is also likely that a proportion of polio
resources will be funded through
In many countries, the deployment special COVID-19 allocations during
of the core polio team – especially 2021. This will help to operationalise
at the subnational level – to support a more integrated polio-related health
countries’ efforts to fight COVID-19, emergency response, in particular at
whether that be surveillance, contact the country and subnational level.
FOURTH TIMB REPORT 31SECURING AND EXPANDING VACCINE-
PREVENTABLE DISEASE SURVEILLANCE
For decades, there has been a strong As early as 2003, 131 countries, or 66%
interdependence between polio of countries globally, had adapted their
surveillance and other vaccine- polio surveillance systems for surveillance
preventable disease surveillance. This of measles and other vaccine-preventable
system has been, and remains, very diseases. This trend has continued so
critical. It is the “eyes and ears” of the that it currently applies to the majority of
immunisation programme, able to see countries.
how it is functioning in the control
and prevention of vaccine-preventable A key part of the polio infrastructure is
diseases. the local surveillance officer. They do
active case-finding, by going to health
Polio is a vaccine-preventable disease, facilities to look for cases. They also
and its eradication needs other vaccine- conduct supervisory visits to make sure
preventable disease surveillance in the clinicians understand what they should
longer term to be sustained. Surveillance, be reporting. They provide training and
other than polio, needs polio resources, feedback to those reporters. They attend
particularly the infrastructure that the meetings where they, themselves, are
eradication effort has put on the ground trained and where they review data.
and the funding that has flowed through Ideally, they should have a close working
the system. In large part, the funding relationship with immunisation focal
of comprehensive vaccine-preventable persons and with other surveillance
disease surveillance comes from polio officers at higher reporting levels.
eradication. It is vital to maintain the The surveillance officer does not just
stability of that infrastructure and look for one disease. They have many
funding into the future. responsibilities.
The global vaccine-preventable disease For acute flaccid paralysis detection– a
laboratory structure has provided time-honoured system that is used
infrastructure, expertise, and staff to in polio surveillance – approximately
support the COVID-19 response. It has two cases per year for every hundred
been instrumental in kick-starting the thousand people might be detected and
implementation of COVID-19 diagnostics investigated. That takes up only a small
in many countries. So, the presence of part of a surveillance officer’s time. For
this whole surveillance infrastructure has measles and rubella, that detection rate
also been an underpinning foundation for could be anywhere from two to hundreds
the response to the COVID-19 pandemic. of cases per year, depending on how
good a level of control there is in the
The subject of surveillance became country or in the area.
one of the key focus areas of the polio
transition planning process early on. It Surveillance officers are also case-
was recognised that polio resources were finding, investigating and analysing data
subsidising activities in the field and for all the other vaccine-preventable
in laboratories vital to preventing and diseases, such as neonatal tetanus,
controlling other diseases. meningitis, acute encephalitis syndrome,
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