How to Eradicate Polio in Pakistan: Insights from Community Health Workers

"There are critical insights available if we listen to people who are instrumental to the success of health programs, but not commonly involved with creating policy."

The Polio Eradication Independent Monitoring Board (IMB) has urged that "improving communication - in particular, starting with sensitive listening - should be at the heart of the polio programme at every level". This recommendation may be particularly pressing in Pakistan, which is one of two countries where wild poliovirus is still endemic. Frontline workers (FLWs) are the staff most intimately familiar with both vaccine coverage challenges and the community context. Thus, from 2020-2022, these researchers engaged FLWs in 18 super-high-risk union councils (SHRUCs) in Pakistan through a human-centred design (HCD) ideas competition, which focused on listening to the people who know the polio programme best. This article outlines FLWs' insights and suggestions for improvements to the polio programme.

The article begins by describing the methodology of the HCD ideas competition, which centred around brainstorming sessions and culminated in a pitch competition. Over the course of 2 rounds of the process, the researchers received 189 idea submissions from 171 teams; 9 were chosen for implementation.

The researchers conducted 3 rounds of in-depth interviews over the course of the project. They spoke with 63 polio FLWs, managers, and higher-level officials before round 1 for a diagnostic study, 25 after round 1 to gather feedback on their process to make improvements, and 28 at endline, after round 2. For participant observation, members of the research team accompanied polio workers, at the frontline and management levels, in their daily activities, including door-to-door vaccination, data collection, social mobilisation, and data compilation, during the polio campaign cycle of June 2021.

The suggestions of FLWs on how to eradicate polio fell into 4 main categories:

1. Tackling community fatigue - In a single polio campaign, every household was visited by FLWs multiple times. Many of these visits involved data collection (especially from refusal households, including their names, phone numbers, tribe, political affiliations, religious/sect affiliation, and potential influencers) but no service provision, which could sometimes serve to add fuel to conspiracy theories that the polio programme was connected to police or international military operations. The cycle of visits was repeated for each campaign: 8-10 times in 2021. Many FLWs reported that some households experienced these repeated visits as unnecessarily invasive of privacy and personal space. They wrote that repeated visits increasingly caused refusals, as people were tired of responding to so many disruptions to their daily life. FLW suggestions included: fewer visits, fewer campaigns, and better timings for home visits, as well as less data collection and better data management.
2. Strengthening primary health care - There were calls to improve primary health care in SHRUCs as a way of addressing community frustrations over an intense focus on just one disease in the context of numerous acute needs. Teams tackled various aspects of these issues in their competition idea submissions, presenting a range of solutions, such as holding health camps, improving government clinics, coordinating between water and sanitisation services and households, and providing medicine, nutritional supplements, maternal care, and other co-delivered services during polio campaigns themselves.
3. Increasing community engagement through locally relevant channels - FLW suggestions focused on engaging religious influencers (who can give assurances to the community that the polio vaccine is Islamically permissible), managing refusals by doctors and government workers (who were more likely to influence other families to refuse the vaccine), introducing educational videos, creating a polio dial-tone, and making changes to school curriculums to improve polio knowledge among young people (who may not have seen someone affected by it).
4. Improving human resources processes and workplace dynamics - FLWs recommended reducing overtime work, improving hiring and training, tackling violence from the community, offering spaces to discuss problems at work confidentially and openly, and implementing longer-term contracts for workers.

Some clear policy recommendations emerge from the ideas of FLWs. In their calls for action in these areas, they are not alone; their observations on reducing campaign fatigue, the need for integration, and increasing community engagement are echoed in the literature, as well as in recommendations and programmatic changes underway from within the polio programme itself. Across these ideas, one repeated concept is the need for balance between the intensity of polio activities required for eradication and the provision of other government services, including health services.

The researchers comment on the deep engagement of FLWs in the process of idea generation, noting that "there is no one more qualified to speak to the issues on the ground than FLWs. It became very clear to us through the course of this work that the polio program's frontline workers are committed, intelligent, thoughtful women. That their insights are being brought into the polio program's policymaking is a pathbreaking step that could be a model for other programs."