Emergency Operational Plan for 2024 [Pakistan]

"Communication strategies, social behavior change, media engagement, and partnerships are pivotal for creating lasting behavioral change and sustaining social norms."

In 2011, the outbreak of poliovirus in traditional reservoirs of Pakistan compelled the government to declare it a national-level public health emergency. Since then, the National Action Plan on Polio Eradication (NEAP) has been regularly revised in alignment with the Global Polio Eradication Initiative (GPEI) Polio Eradication Strategy in an effort to halt poliovirus transmission definitively. Published by the Ministry of National Health Services, Regulation and Coordination
(National Emergency Operations Centre for Polio Eradication), the 2024 NEAP emphasises urgency, accountability, increased ownership, and political drive at all levels, focusing on flexibility at the district and sub-district levels.

The overarching strategic goal of the plan is to effectively halt the circulation of endemic poliovirus within South Khyber Pakhtunkhwa (KP) while simultaneously ending all poliovirus transmission in the rest of the country by the end of 2024. To support that goal, the polio programme in Pakistan is applying a risk-based approach to plan and conduct different interventions that involves classifying districts into 4 main categories based on epidemiology and risk: All South KP districts are categorized as Endemic; districts with wild poliovirus type 1 (WPV1) case detection or environmental surveillance signals in 2023 fall under the Outbreak category; 52 districts are identified as Risk Reduction areas; and 81 districts fall into the Maintenance category.

By the end of the year 2023, the programme had achieved great successes in terms of localising endemic virus circulation and also demonstrated ability to mitigate the risk of large-scale outbreaks from the imported virus. By the end of the year, overarching challenges included: inaccessibility in some areas, high population mobility and difficulties with reaching children on the move, vaccine refusal (including fake finder marking, or FFM), and low routine immunisation coverage. Thus, specific priorities for the next 6 months include executing planned vaccination campaigns, reaching missed children and high-risk mobile populations, resolving community boycotts, addressing mistrust, and implementing high-quality outbreak response campaigns, especially for special populations and in critical areas. The plan emphasises cross-border coordination with Afghanistan, including the synchronisation of campaigns and strategies to ensure vaccination for special populations on the move.

After the NEAP explains plans for supplementary immunisation activities (SIAs), including outbreak responses, and surveillance activities, the document turns to focus on the communication strategy, social and behaviour change (SBC), media, advocacy, and partnerships. As outlined here, the integration of human-centred design (HCD) and behavioural insights into SBC interventions is pivotal for fostering positive and sustainable social change. By prioritising the community through HCD, the polio programme ensures cultural sensitivity and adaptability. In addition, incorporating behavioural insights provides a nuanced understanding of motivations, allowing for the development of targeted and effective interventions. This comprehensive strategy, complemented by mass media, advocacy efforts, and strategic partnerships, is designed to strengthen the ability to create lasting behavioural change and promote community engagement.

Examples of communication-related priorities include:
 

• Shifting SBC from focusing solely on refusals to an all-missed-children approach;
• Conducting social profiling of missed children to gain insights into factors associated with vaccine refusal and develop tailored strategies to address concerns;
• Identifying and engaging religious / political / tribal / local influencers who are language- and culture-matched to build trust with refusing families for effective engagement and conversion;
• Developing and implementing a systematic framework of identification of hard-core refusal families and optimal influencers for these families;
• Implementing social listening and social information gathering frameworks to identify children who are finger-marked without vaccination, and designing and implementing customised SBC interventions that are based on research and findings to mitigate the challenge of FFM;
• Building on the gains made through grey house strategy to identify and vaccinate children hidden from polio teams;
• Providing SBC support to resolving boycotts (e.g., through participatory community engagement and social mobilisation to help mitigate the issue of polio vaccination used as leverage and a bargaining tool to settle community disputes);
• Supporting local problem solving and micro-innovation in designing Integrated Service Delivery (ISD) initiatives that are based on the HCD approach;
• Ensuring effective and accurate and challenge mapping to form evidence for SBC interventions and guide programme direction;
• Engaging religious entities, building on the National Ulema conference 2023;
• Developing advocacy strategies and enhancing multi-sector partnerships with key public and private institutions and high-level national and provincial influencers;
• Creating an enabling environment for sustaining social norms for vaccination countrywide and increasing vaccine acceptance in high-risk areas through mass media, social media, and outdoor visibility; and
• Forming partnerships with journalists and media houses to build sensitisation on optimal reporting on polio.

The NEAP describes the collaboration between the Expanded Program on Immunization (EPI) and the Polio Eradication Initiative (PEI) as a crucial step in fortifying routine immunisation efforts over the next 6 months. It also presents a 6-month integrated action plan for endemic union councils (UCs). Detailed operational activities by districts and identified UCs are outlined in an accompanying spreadsheet. The plan emphasises proactive measures, community engagement, and cross-border collaboration to ensure the success of the high-risk emergency operation plan. For example, social mobilisers should be present at every health care facility with ISD interventions to engage and mobilise communities for the provision of other attractive services (e.g., basic health care) aligned to the needs of communities, which can provide additional opportunities to offer oral polio vaccine (OPV) to children outside the planned campaigns and routine immunisation schedule.