Effective Partnership Mechanisms: A Legacy of the Polio Eradication Initiative in India and Their Potential for Addressing Other Public Health Priorities

"The success of the CGPP arises from its ability to manage partnerships with diverse organizations that are working at various levels and that have very different capacities."

While many factors contributed to the successful elimination of polio from India, partnership and coordination mechanisms at multiple levels that have evolved over the years have been important elements. This is the central argument of this paper, which is part of a series of articles detailing the work of the CORE Group Polio Project (CGPP) (accessible through Related Summaries, below). The authors assert that the learnings and expertise of the CGPP in developing, managing, and nurturing partnerships can be adapted and replicated in other context for elimination or controlling other diseases and for ending preventable child and maternal deaths.

The partnership and collaboration model developed by the polio eradication programme in India was the result of collective efforts of: the government; United Nations (UN) agencies; non-governmental organisations (NGOs) at the international, national, and local levels; and other partners who worked to ensure that every last child was reached and immunised with oral polio vaccine (OPV). The CGPP is one of the partners in the national polio eradication programme, whose efforts resulted in the certification of India as polio-free in March 2014.

Based on a review of the literature, the article presents a definition of, and a conceptual framework for, partnership. A partnership comprises organisations that have common goals and objectives and that combine resources to implement collective activities. Partnerships can prevent duplication of efforts, ensure synergy of resources, and augment the overall leadership within the country. Table 1 in the paper describes the continuum of 3 aspects of organisational relationships: (i) the paradigm under which the relationships operate, (ii) the goals of the relationships, and (iii) the structure of the relationships. Coalitions have been recognised as vehicles for identifying and prioritising system-change strategies and for making the changes happen. Partnerships have been identified as playing a central role in enabling community coalitions and community-based health programmes to achieve system change and address health disparities.

The article next describes partnerships at 2 levels:

1. The CGPP partnership, in which international and national NGOs collaborated together at the country level under the leadership of a secretariat to support polio eradication activities - The CORE Group is a membership association of more than 100 international NGOs that strengthen local capacity on a global scale to improve the health and well-being of children and women in developing countries. In 1999, the CORE Group received USAID funding and established the CGPP with the purpose of engaging NGOs in polio eradication through social mobilisation, community-based surveillance for acute flaccid paralysis (AFP), cross-border coordination, and related activities. The CGPP structure includes a secretariat in each country where it operates, CORE Group international NGO members, and their local NGO partners. The CGPP secretariat in India works in collaboration with the Ministry of Health and Family Welfare, the government of India, the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), Rotary International, and USAID. Four partnerships evolved over the life of the project:
   • The CGPP/India working with USAID, the CORE Group, and CGPP global headquarters in the US;
   • The CGPP/India Secretariat, coordinating the consortium of international, national, and local NGOs and other community-based organisations;
   • The CGPP/India, working with the Social Mobilization Network (SMNet), UNICEF, the WHO National Polio Surveillance Project (NPSP), and Rotary International; and
   • The CGPP/India, working with the government of India.

   The CGPP secretariat, as well as UNICEF, the NPSP, and Rotary International, transferred the strategies and implementing activities developed at a higher level down to the local field level through their respective organisational channels while at the same time communicating grassroots-level voices to policymakers. The CGPP secretariat also provided technical support to its collaborating NGOs - e.g., trainings.

2. The partnership among governments (national and states), the WHO, UNICEF, Rotary International, and the CGPP - The role of each partner was well defined and distinct to ensure complementarity and to avoid duplication of effort. The partnership between various stakeholders was achieved using multiple mechanisms such as coordination meetings among partners at the sub-national and district levels, as well as the Social Mobilization Working Group, which consisted of representatives from UNICEF, the WHO-NPSP, the CGPP, Rotary International, and the government of India. This group frequently discussed the communication and social mobilisation challenges of the polio eradication programme and suggested necessary changes in the strategy. A main strategy developed through the partnership was SMNet. The CGPP and UNICEF developed various materials for training, behaviour change communication, supervision, and human resource management with uniform guidelines. For smooth and effective coordination, mechanisms were created to address SMNet's implementing challenges. These structures were made functional through frequent engagements, such as meetings, field visits, and task force meetings held by the CGPP secretariat and other partners. For example, village-level Social Mobilization Working Groups and interface meetings helped to mobilise local resources to address local issues in a timely fashion. Figure 7 in the paper details the institutional structures and the frequency of the group meetings.

The article explores various challenges faced by the CGPP. For example, in the first few years of this collaboration, supplemental immunisation activity (SIA) rounds were conducted every month. Some NGOs were not used to this type of intensive, almost continuous campaign work. So, working with UNICEF, the CGPP strengthened the SMNet by institutionalising uniform nomenclature and terms of reference for workers/staff and their training. Furthermore, during the course of implementation over an 18-year period, various changes in the CGPP partners have taken place. The CGPP and SMNet addressed these and other challenges through facilitation, understanding of the complexities at the ground level, and establishment of effective and regular communication between the community, NGOs, government, and donors.

Figure 8 shows the downward trend in the percentage of missed households that were attributable to resistance that occurred after involvement of SMNet mobilisers began. This, according to the authors, is strong evidence of the effectiveness of the partnerships for polio eradication in India. Figure 9 shows the percentage of missed houses in the districts covered by the CGPP, comparing the outcomes for those districts with community mobilisation coordinators (CMCs) with those where CMCs were not working.

In reflecting on the partnership experience, the authors note that the CGPP "proved to be a good example of a consortium of NGOs coordinated by a secretariat that is not directly involved in implementation." They contend that "[t]he success of the SMNet in contributing to the elimination of WPV transmission in India is evidence that the secretariat model was effective in enabling international, national, and local NGOs to develop strong long-term partnerships in which mutual respect emerged and in which each organization recognized that all participating organizations were complementing the capacities of the others. Field-based learning and continuous analysis of inputs, processes, and outputs were responsible for the emergence of such strong partnerships. The secretariat model enhanced the partnerships because it facilitated NGO representation in the immunization task force at state and national levels."

Among the characteristics of the partnership that the authors believe contributed to its success (see also Table 2.26): A high level of enthusiasm between all the partners could be sustained for a long period of time because of the shared goal of polio eradication; motivation was sustained because of the measurable reduction in polio cases. In addition, the CGPP secretariat and consortium model ensured transparency regarding the structure of the partnership and the participatory nature of decision-making. The model was also able to establish accountability resulting from participatory monitoring and peer influence.

As suggested here, obtaining legal registration for the CGPP secretariat in India would help to sustain the brand value of the CGPP and its relationships with the community and the government. It would also enable the secretariat to address other public health issues in India.

The lessons learned from these partnership and coordination mechanisms among various stakeholders involved in service delivery, surveillance, community mobilisation, and governance are as a legacy of the programme. More strongly: "Maintaining and further strengthening the partnership model for polio eradication in India and using it to address other public health priorities in India could be the real legacy of the Polio Eradication Program in India."