Chapter 4: Polio Eradication: the final challenge
Finding the people
While strong political engagement and substantial financial and in-kind resources are essential to the success of the polio initiative, they are not sufficient. These two elements have had to be complemented with sufficient people to implement the eradication strategies in every corner of the world. Although high-income and higher-middle-income countries could usually rely on strong health services to implement the eradication strategies, a massive gap in the critical area of human resources for health, particularly in low-income and lower-middle-income countries with the greatest polio burden, threatened the success of the entire global effort.
The number, mix and distribution of people required to eliminate polio from countries differed, depending on the strategy. The most labour-intensive strategies were the massive, time-limited, supplementary immunization activities such as NIDs and "mop-up" campaigns. The most skill-intensive strategy was that involving continuous disease surveillance and laboratory activities. In general, the very different human resource requirements of the two types of strategy were met through different approaches.
The number of people required to implement NIDs is tremendous. As noted above, an estimated 10 million volunteers and health workers immunized 575 million children during such polio eradication activities in 2001. Two key aspects of NIDs were critical to resolving the gap between existing, trained vaccinators in a country and the number needed for NIDs. First, because NIDs only require administering 2 OPV drops to a child and then recording the number immunized, with 1--2 hours of training community volunteers could safely deliver the service. Second, the time-limited nature of NIDs meant that volunteers were willing to participate and that other government ministries, nongovernmental organizations and private sector partners could bear the opportunity costs incurred by having their staff participate. Consequently, the major challenge for national and subnational health authorities and the polio partnership became the mobilization, training, equipping and management of these human resources. Given the scale of this mass mobilization, a substantial effort was made to include other interventions in NIDs where feasible and safe: it has been estimated that the inclusion of vitamin A supplementation in polio NIDs averted 1.25 million childhood deaths (9).
The high-quality surveillance required for guiding supplementary immunization activities and monitoring their impact called for a different human resources response. Far fewer people were required than for NIDs, but with a much higher level of skills to identify, notify, investigate and respond to cases of AFP (4). Furthermore, they had to be available on an ongoing basis. Consequently, the polio partnership focused on working with national authorities to expand and strengthen the existing national surveillance infrastructure wherever possible. Where this infrastructure was functionally non-existent, partners worked with national authorities to establish AFP surveillance. In any particular country, the strategy pursued to close this human resources gap depended on the broader national strategy for strengthening health services. In some countries, surveillance personnel received government salaries with operating costs, including vehicles and equipment, covered by international sources. In other countries, national salaries were supplemented by partners as part of a government strategy to retain highly qualified staff. In still others, WHO and governments established and operated a joint surveillance programme. In addition, WHO hired and deployed nearly 1500 national and international staff to provide technical assistance and even conduct surveillance activities in those areas with the weakest capacity.
Through this mix of strategies and approaches to the gap in human resources for health, it has been possible to reach almost every child in the world with OPV and other interventions (such as Vitamin A supplementation), irrespective of socioeconomic status, religion, minority status, geography or even war. In addition, a truly global surveillance and laboratory capacity now exists to identify and respond rapidly to polio, as well as to many other diseases of public health importance such as measles, neonatal tetanus, meningitis, cholera and yellow fever, depending on the country (10). In the Western Pacific Region, this capacity contributed to the international response to the SARS outbreaks of 2002--2003.