From Legacy to Integration in the Global Polio Eradication Initiative: Looking Back to Look Forward

"[T]he critical dynamics in transition programmes are not just technical and financial - they are also relational and social. Close attention to all of these factors will be critical in the transition of polio and other single-disease vertical programmes."

The Global Polio Eradication Initiative (GPEI) is a huge single-disease vertical public health programme that sought to eradicate poliovirus globally by the year 2000. It provides an example of the opportunities and challenges of transition efforts: the process of shifting from donor-funded, single-disease programmes to programmes with more integrated and sustainable programmatic and funding streams. The purpose of this paper is to analyse the social and political dynamics of the polio transition in the 2010s to provide insights into today, as well as lessons for other programmes.

This paper is part of a larger study, Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE). The researchers conducted semistructured interviews with GPEI officials involved in transition planning across GPEI partner agencies (n=11). They also drew on document review and interviews with national and subnational actors in Nigeria, India, Ethiopia, and the Democratic Republic of the Congo (DRC). They inductively analysed this material to capture emergent themes in the evolution of transition activities in the GPEI.

When polio eradication was adopted by the World Health Assembly as a goal in 1988, the plan was to eradicate polio with a lean and ephemeral infrastructure. Although this plan unfolded as envisioned in many areas of the world that at the time had stronger health systems, in sub-Saharan Africa and South Asia, polio proved much harder to eliminate. Over time, GPEI's investments in infrastructure and staffing in persistently polio-endemic countries expanded, and the GPEI built extensive social mobilisation networks for polio eradication in many countries, funded and staffed by GPEI partner the United Nations Children's Fund (UNICEF). The interviewes revealed that, since the mid-2010s, GPEI actors expressed concern that assets such as these should not be lost when polio was eradicated.

Planning for polio's legacy, however, proved complicated. The GPEI's commitment to and focus on eradication had taken precedence over strong collaborations outside the polio programme, making building alliances for transition challenging. There were also complex questions around who should be responsible for the transition process, and which agencies would ultimately pay for and deliver polio-funded functions. Several respondents commented on the path dependence of transition efforts: They were quite self-critical that they, as polio eradicators, had not built bridges earlier with other programmes.

The myriad tensions over who would fund continuing activities, and be responsible for planning transition, resulted in the discontinuation of the transition effort. Not all priority countries developed transition plans. Current efforts to achieve "integration" (e.g., providing more services, beyond polio vaccine, to combat community fatigue) both have great promise and must grapple with various issues. Draft documents (2023) emerging from a Geneva, Switzerland, forum show much learning from the past: (i) an emphasis on the need to fund some polio functions, such as surveillance, as global public goods; (ii) a focus on the need to support national health systems; (iii) awareness that in some fragile countries, governments cannot take over polio functions; and (iv) a focus on coordinating donor financing. All of areas of focus these reflect both a continued commitment to transition and an effort to avoid repeating the experience of the previous transition era.

One key lesson from the transition era articulated by many respondents is that the GPEI will have to relinquish some control over its activities and engage in intentional coordination with other programmes. If polio is to work in partnership with other programmes to achieve integration (and it would have to, because the polio programme does not have expertise in areas like nutrition), respondents reflected it would be critical to share power over decision-making.

In reflecting on the findings, the researchers argue that achieving integration will require close and thoughtful attention to the social and political dynamics at play, with plans to address them effectively, including:

• Shift the command-and-control orientation of the polio programme.
• Build connections across programmes, both to create relationships and to illustrate the value of polio infrastructure.
• Undertake clear planning as integration proceeds to avoid the most painful aspects of polio funding drawdowns.
• Be aware of the fact that, in areas where the polio programme has the most extensive infrastructure, it is likely to be infeasible to integrate with other programmes or transition to any other actors. Areas that are in clear need of health services will require sustained support. "The polio programme reaches people that other programmes, governments and health systems neglect. Integrating and providing sustained funding for these services could be a powerful way to increase health equity globally."

In conclusion: "Many respondents argued that the polio programme would have benefited from some transition planning early on, when opportunities to work collaboratively had been bypassed in favour of a vertical approach. In this they echo sustainability and transition scholars who argue that sustainability should be planned early....[I]t is important to build robust relationships with other programmes, particularly government health systems, to respond to their needs and build collaborations that can eventually form the bedrock of the transition phase of the programme. Programmes built to transition could ensure that their short-term gains can set the stage for more robust health systems down the road."