Chapter 4: Polio Eradication: the final challenge
Scaling up the delivery of health services
The greatest success of the polio eradication initiative to date has been its capacity to reach virtually every population in the world with a basic health service, regardless of geography, religion, conflict or even the strength of the health system. This experience in scaling up to implement fully the eradication strategies is now one of the most valuable assets of the programme. Perhaps the most frequent, if unfair, criticism of the highly regarded smallpox eradication effort was that it left little infrastructure behind to tackle other diseases. Indeed, the ultimate legacy of the polio eradication initiative will depend largely on the extent to which the experience and lessons learnt are used in scaling up the delivery of other health services.
Although political engagement, partnership management and financing were essential components of the scale-up, these approaches alone were not sufficient in areas with particularly weak health systems. In such areas it was only possible to achieve scale-up after other fundamental gaps in the health system had been tackled. At the central level, joint national and international technical advisory bodies, established at either the regional or national level, helped strengthen and support policy-making functions. Substantial international technical assistance then helped build national capacity to translate these policies into local guidelines and procedures, while assisting national bureaucracies to "jump start" their implementation. At the sub-national level, national staff were trained or hired to perform these functions. In general, a very pragmatic approach was taken to ensure appropriate remuneration for the work that was conducted. Great emphasis was placed on establishing national capacity to monitor and evaluate strategy implementation effectively at each level, using standard and robust performance indicators for every aspect of the programme, from the collection of stool specimens from suspect cases to the cost per child immunized.
At the level of service delivery, the major challenges related to creating and then meeting demand for immunization with OPV. Demand creation was usually a major issue only in urban areas; in rural settings, the simple availability of the service was often sufficient to create the necessary demand, and this is likely to be the case for other pressing needs such as HIV treatment. Consequently, social mobilization was the principal service delivery challenge in the urban setting while logistics were far more important in rural areas. Mobilizing communities in urban areas required a heavy reliance on radio and television, with carefully tested messages delivered by appropriate spokespeople. In the rural setting, the systematic identification and engagement of traditional and community leaders was the essential foundation for the person-to-person communications that were needed. The logistic demands of actually delivering OPV in urban areas could frequently be met through the formal health services, supplemented by paramedical personnel or students. In the rural setting, gaps in the formal health service required community volunteers for every element of the programme from the collection of vaccine from depots through to immunization, tallying and reporting.
While the importance of all of these elements is widely and well recognized, the strength of the eradication initiative has been in its ability to deal sufficiently with these matters at the international, national and peripheral levels at the same time. This was only possible, however, by deploying substantial numbers of technical and support staff in areas where the formal health systems were weakest; the number of these staff reached nearly 3000 by the year 2001, with 80% in just 15 countries.
Many of the newer international disease control initiatives, such as those targeting other vaccine-preventable diseases, AIDS, tuberculosis and malaria, must deliver more complex interventions than OPV. Nonetheless, the lessons learnt through polio eradication in filling gaps in the health system are also applicable to scaling up the delivery of such services. For example, the success of these newer initiatives will also require the active participation of communities on a massive scale to close the gap caused by insufficient numbers or distribution of trained health workers. Optimizing the engagement of volunteers -- whether to deliver bednets, conduct HIV education, or distribute drugs and ensure their consumption -- will also require supply lines that can provide every community with the necessary tools on a predictable, if intermittent, basis.
Optimizing the potential benefits of the polio eradication infrastructure, experience and lessons will require strengthening linkages with newer programmes to scale up access to these important health interventions. WHO is firmly committed to strengthening these links for the benefit of all peoples everywhere and being as bold with the new interventions as Cuba was in rapidly scaling up the use of OPV.
Progress in eradicating this debilitating disease clearly demonstrates that national governments, backed by strong international partnerships, can generate and manage the political leadership, financing, and human resources needed to reach all populations with health interventions. The ultimate success of the polio eradication effort, however, is still not guaranteed; it now rests with the leaders of a very small number of endemic areas, who must ensure that all of their children are immunized, and the leaders of wealthy countries, who must act on their verbal pledges to close the chronic financing gap for these activities. In meeting these challenges, the world will create a global public good for health whose benefits will accrue to all children, potentially for ever.
This chapter has chronicled the long and difficult war against one of the world's oldest diseases. Chapter 5 is the story of the brief but deadly encounter with one of the world's newest threats, SARS -- how a vital victory was achieved, and the lessons it offers for the future.