This 45-page report details an independent, external evaluation of the Global Poliomyelitis Eradication Initiative (GPEI) that was carried out in response to a request from the Executive Board of the World Health Organization (WHO). The report is part of a package that consists of an Executive Summary and 5 full reports from 5 separate evaluation teams, focused on: Nigeria, India, Pakistan, Afghanistan, and the international spread of polio.
The evaluation team worked in Pakistan from August 24 to September 1 2009, conducting a desk review of relevant documents, site visits to 3 provinces, interviews with stakeholders, and meetings with community members and lady health workers (LHWs) and their supervisors.
Communication-related strengths include:
- There is strong political commitment to implementing polio campaigns, although the degree of ownership and financial support vary from province to province. Political blessings and the presence of high-level policymakers at campaign launches have raised the profile of polio vaccination. The working relationships and coordination between the government, WHO, and the United Nations Children's Fund (UNICEF) are positive.
- Finger-marking is an objective and transparent tool to assess campaign coverage. This type of evidence helps to hold campaign teams accountable for their work at the Union Council level, and was used as a guide to improve campaign coverage in subsequent National Immunisation Day (NID) and Sub-National Immunisation Day (SNID) rounds.
- In most areas that the evaluation team visited, polio teams had engaged in efficient micro-planning, and efforts were made to increase effective coverage with hard-to-reach populations through social mapping (which was useful for identifying population migration patterns and covering internally displaced persons (IDPs) and nomad populations).
- Inclusion of female team members and LHWs with knowledge of local languages was helpful in gaining access to otherwise restricted households.
- Team meetings with zonal supervisors and field supervisors monitored progress, solved immediate problems, and ensured the accountability of campaign teams.
- In North West Frontier Provinces (NWFP)/Federally Administered Tribal Areas (FATA) the evaluation team found highly committed health teams given the insecurity that permeates that region. Local knowledge was applied to gain access to security-compromised areas by such means as peace negotiations with militants, the use of transit teams that can immunise children on the move (especially those moving in and out of security-compromised areas), cross-border immunisation services, and identification of IDPs living with host families and in camps.
Communication-related weaknesses include:
- The dynamic population migration and wild polio virus (WPV) transmission, either through internal or external Afghanistan-Pakistan transborder crossing, poses serious challenges to polio eradication.
- The polio and routine Expanded Programme on Immunisation (EPI) operates with limited resources, the primary health care (PHC) infrastructure is weak, and there is a lack of human resources.
- Political interference in appointing vaccinators and holding them accountable for their performance is a major problem in some provinces. Authorities know of this concern, but few are taking appropriate sanction and disciplinary actions. The evaluation team noted micro-level management problems, a lack of transparency, and weak leadership in several programme areas.
- The general public is somewhat suspicious of oral polio vaccine (OPV). Mothers report that their questions about 7 doses are not being adequately addressed by provincial and district government officials, vaccinators, or the media.
- Apart from monthly salary, there is no additional incentive for vaccinators providing routine EPI services, either through outreach or fixed sites.
- Data for the EPI coverage rate are not precise due to the problems with identifying correct denominators; the high routine EPI coverage rates create a false sense of security among policymakers.
- Discussions with community members and LHWs confirm high awareness among the general population about the time and place of polio campaigns. There is, however, a lack of knowledge and understanding about polio and the need for polio immunisation, and a need to educate the population about the difference between polio vaccination and other routine immunisation (RI). The EPI communication strategy is not effective in explaining polio and polio immunisation, as it tends to be campaign-specific and does not generate demand for immunisation among the public. Messages focus on the dates and places of campaigns rather than providing culturally sensitive and contextually appropriate messages.
- There are persistent rumours and misconceptions that link polio vaccination with sterilisation or infertility, and very little effort has been made to address this issue.
- There is no earmarked budget for communication activities by the different level of governments.
- The large populations of infants and under-five children in all provinces strains the existing PHC infrastructure. Competing demands on health worker time - for example, the need to conduct Dengue fever or treatment of tuberculosis at the same time as polio campaigns - has resulted in health worker fatigue.
Communication-related recommendations include:
- Governance: Remedial actions need to be taken with regard to: nepotism, the lack of transparency with regard to the transfer of monies (especially to the polio team workers), and political interference in the appointment of health workers at the micro-level. Specific persons need to be identified who will be held accountable for the management of polio campaigns in all provinces.
- Surveillance and Campaign Implementation: Efforts should be given to produce post-campaign coverage assessment using finger-marking at the Union Council level, not the district level. These assessment data should be used to respond to the immunisation needs at the Union Council level, and as a means for holding teams at each Union Council accountable for their work.
- Routine EPI and Polio Campaigns: The government and development partners need to improve the demand for and delivery of RI and improve the performance of EPI coverage through significant strengthening of outreach teams and increased role of LHWs in provision of EPI services.
- Communication Strategy: There is a need to review the communication goals and objectives for polio vaccination and RI, to develop messages that create demand for RI services, and to deliver clear and culturally appropriate message to address rumours, misconceptions, and misinformation in the general population. Innovative approaches to communication should be tried.
- Further Research: Operations research to determine the efficacy and effectiveness of conducting campaigns - as well as qualitative and quantitative research to determine the true knowledge, attitudes, practices (KAP), degree of self-efficacy, and other dimensions of behavioural change with regard to polio and RI - are needed in order to create an evidence base upon which to build communication campaigns to support the polio eradication effort. Although there are a number of KAP studies and barrier assessments for all immunisation, there is a need to further review if there are still gaps that operational research can guide effective programme implementation.
- Healthcare Infrastructure: It is important to communicate and collaborate with other Ministries and agencies (e.g., Education, Information and Broadcasting, Women, and Environment) to develop a holistic approach to immunisation and child health.
- LHW Programme: The LWH programme is key toward strengthening the PHC system. This programme should be scaled up.
WHO Polio website, accessed December 16 2009. Image credit: WHO