The Struggle for Progress: Does System Strengthening Always Have to Be Slow?

"Building trust through community engagement and transparent communication will be crucial."

The Global Polio Eradication Initiative (GPEI) created the Transition Independent Monitoring Board (TIMB) in 2016 by to monitor and guide the process of polio transition planning. The GPEI asked the TIMB to make its meeting, in July 2024, a joint meeting with the Independent Monitoring Board (IMB). This report, the TIMB's seventh to date, deals only with the TIMB's monitoring responsibilities. (See Related Summaries, below, for the IMB's 23rd report: The Long Goodbye: The Poliovirus Continues to Resist Extinction.) The report assesses the current thinking of GPEI partners on polio transition and judges the extent of progress with implementation. The summary below focuses on some of the report's communication-centred elements.

At the outset of the report, the TIMB stresses that "the early promise set out at the first TIMB meeting, that a polio transition programme, through the polio assets and expertise that it held, would be a catalyst for countries to speed up the development and strengthening of their entire health systems, seems now a forlorn hope. Many countries, especially in sub-Saharan Africa, South Asia, and conflict-affected regions, are not yet ready to manage these functions independently. The challenge is further complicated by the extensive circulation of vaccine-derived poliovirus which is now causing much more paralytic polio than the wild poliovirus."

The TIMB points out that for many stakeholders, the language of "transition" itself is confusing. The group proposes this lens: "Polio transition should not be seen as an 'exit strategy,' where partners simply withdraw upon completion. Rather, it should be viewed as a maintenance and sustainability strategy designed to uphold the Polio Programme's achievements and maintain its assets so that eradication gains are protected and integrated within broader health systems."

One of the programme's achievements can be seen in the concrete examples of how civil society organisations (CSOs) have contributed to polio integration and transition. To cite only a few:
 

• CSOs have been instrumental in advocacy at both national and community levels. In the Democratic Republic of the Congo (DRC), 18 CSOs advocated for increased funding for polio transition, and they used media platforms, including television and radio, to build public pressure on the government to deliver on its immunisation commitments.
• In polio-endemic Afghanistan, organisations like the Afghan Red Crescent Society and the UNFPA (the United Nations sexual and reproductive health agency) have taken steps to integrate polio immunisation into broader health services, leveraging existing community health structures to reach remote populations. The positive attribute of such models of delivery lies in their community-driven nature. Community mobilisation work, led by Health Shuras and Family Health Action Groups, enhance local ownership of health initiatives, making services more sustainable and accepted by the population. The impact of these integrated health approaches has been significant, per the TIMB. In the south of Afghanistan, for instance, over 223,000 children have received oral polio vaccine (OPV) doses, and nearly 14,000 previously missed children have been reached.
• In Somalia, the Far-Reaching Integrated Delivery (FARID) project (see Related Summaries, below) has highlighted several key lessons, including the importance of integrated services in hard-to-reach areas, where communities are more receptive to polio immunisation when it is bundled with other essential health services. Community trust and respect for local leadership structures were critical in overcoming barriers and ensuring service delivery.
• On that note, one of the most significant roles of CSOs in the transition period is to ensure the integration of polio functions into the broader health system, including by: sustaining polio vaccination coverage even as the disease is eradicated and integrating polio resources into essential immunisation programmes.

The eradication effort has also highlighted the role local gender norms play in determining access to children, decision-making around health care, and refusals of vaccinations. These norms, therefore, must be carefully understood and addressed in the design of the polio eradication and transition programmes. One of the challenges going forward is the need to resist making the assumption that increasing the number of female health workers alone will automatically lead to better access. In patriarchal societies, where men ultimately make the decisions, the presence of women vaccinators alone is insufficient. Male decision-makers must be engaged directly through social and behavioural change communication activities. Leveraging male social mobilisers to engage with fathers and male elders in regions where male authority dictates health decisions is one promising strategy.

Furthermore, the lack of gender-disaggregated data has important implications for programme planning and evaluation. Ongoing under-reporting of female children, particularly in regions where local norms dictate that girls remain hidden from public records, creates a significant blind spot for planning, leading to discrepancies in vaccination coverage. Practical solutions could involve localised training programmes that emphasise the importance of collecting and using gender-specific data. 

More broadly, the TIMB points to the need for subnational estimates and more granular data, especially in countries driving polio outbreaks and global spread. For many, this missing element represents a call to action to improve the validation of data in polio-endemic or high-risk countries, ensuring that the global community has a more accurate picture of where immunisation gaps remain. There is a particular need for additional scrutiny in countries like Pakistan, Afghanistan and parts of Africa, as they continue to see poliovirus transmission despite reporting suggesting they have high immunisation coverage levels.

Among the points made in the report's conclusion: "There is a growing realisation that the Polio Programme, initially designed to control a communicable disease, may no longer be equipped to handle the multi-dimensional challenges of the final stages of polio eradication. These challenges are not solely epidemiological, they also involve human factors, such as community trust, political engagement and the integration of polio vaccination within broader health systems."

To that end, the TIMB recommends a modern and dependable entity to manage the world to polio-free status. Other recommended actions include: Amalgamate the polio transition and post-certification planning work streams; launch an emergency initiative to rapidly increase inactivated polio vaccine coverage; engage a wider range of stakeholders and experts to clearly define "future owners" of the polio programme; meet the need for age- and sex-disaggregated data; develop valid measures of population polio immunity; and balance containment and research needs. 

Finally, per the TIMB: "Much greater attention should be given to the protection and timely payment of female health workers. Despite their critical role in reaching children for vaccinations, their safety and livelihood are often neglected." Going forward, the TIMB recommends close work with local communities to provide "security measures and fair compensation, ensuring that women are not put in harm's way as they work to eradicate polio....A further broad-based review should be undertaken to look openly and fearlessly at this problem and come up with an early report to address the root causes."