National Emergency Action Plan 2023: Polio Eradication Initiative Afghanistan

"Continued support through 2023 and beyond will be critical to protect past investments and gains mad, and most importantly, ensure that children worldwide are protected from polio forever....Working together with our partners, I am optimistic that Afghanistan will soon be polio-free." - Dr. Qalandar Ebaad, Afghanistan Minister of Public Health

2022 was yet another challenging year for the polio eradication programme in Afghanistan. Inconsistent vaccination coverage, especially in the South, poses a significant threat. The house-to-house vaccination strategy, which has proven to be the best campaign modality to reach all children, could not be implemented across the country due to opposition from local leadership in many of the provinces. Six of the 11 objectives set in the National Emergency Action Plan (NEAP) 2022 were met, and five were partially met. From the National Emergency Operations Centre (EOC), the 2023 NEAP provides a roadmap of what it will take to stop wild poliovirus (WPV) transmission in Afghanistan, which is one of the two remaining endemic countries (with Pakistan). It articulates how the Polio Eradication Initiative (PEI) intends to build on recent successes, reverse setbacks, measure results, create an enabling environment, maintain neutrality, foster coordination, and implement accountability.

In 2022, the programme continued to address low vaccine uptake, especially in areas implementing suboptimal campaign modalities in the South. A variety of communication, community engagement, and social mobilisation activities were deployed, including working with influencers such as religious leaders, grandmothers, and local authorities. Two streams of community mobilisers were deployed (full time and campaign based) to ensure intensity of activities during and between vaccination campaigns.

To cite one example: PEI partner United Nations Children's Fund (UNICEF) used U-report, Viamo remote surveys, and caregiver surveys to further understand community perceptions, awareness, and acceptance of polio vaccinations during the November and December campaigns. U-report is a social messaging tool for registered users (mostly youth), while Viamo is a telephone-based random survey. Caregiver surveys, which are paper-based, were conducted by frontline workers, who administered short questionnaires to caregivers in areas not covered by telephone services. Data gathered throughout the year using each of these means show that most respondents implied they would vaccinate their children during campaigns. The most common reasons for not vaccinating child during campaigns, particularly in the South, included husband not being at home and mother unable to travel to the mosque. The PEI has used these data to inform communication and community engagement gaps and appropriate deployment of frontline social mobilisers for community engagement and mobilisation.

There have been various challenges, including suboptimal campaign quality due to issues such as interference in selection of polio frontline workers, limited female participation, and suboptimal commitment at the local level resulting in suboptimal ownership and urgency. Furthermore, clusters of refusals are a significant concern, with key reasons being attributed to vaccine misperceptions, religious objections, campaign fatigue, and other demands due to lack of health and development services, particularly in marginalised and underserved communities. Qualitative feedback reports from campaign monitors also indicate that use of non-local staff, involvement of young male volunteers, and lack of female mobilizers/vaccinators add to challenges around community acceptance of the polio vaccine. These are exacerbated by insufficient staff capacity and low staff motivation. With more than one and half million new births every year in Afghanistan, reaching newborns is an operational and communication challenge due to a variety of factors including the cultural practice of keeping newborns inside the house for 40 days after birth and the absence of women vaccinators.

Per the PEI, responding to the challenges of missed children and silent and chronic refusals requires strategic focus on community engagement, the involvement of new actors, and reliable evidence to drive decisions. In 2023, the programme will build its community engagement activities through:

• Enhanced capacity of Immunization Communications Network (ICN) and partners (international non-governmental organisations (INGOs), community-based organisations, universities, and local media) to engage with communities to improve knowledge and increase awareness and trust of vaccines;
• Increased accountability of religious leaders, teachers, medical professionals, and women's groups through sustained and systematic community engagement;
• Improved integration of community networks through messaging, training packages and tools through the "One FLW" (frontline worker) and community engagement approach and strengthened partnerships;
• Improved evidence generation on community perception and intent to vaccinate, as well as barriers to vaccination, through innovation; and
• Increased female participation in immunisation activities to improve vaccine uptake.

The programme will focus on 4 pillars:

1. Enhanced two-way knowledge and awareness raising: disseminating accurate knowledge and motivational messaging to caregivers and FLWs to reinforce or change attitudes and perceptions that impact the decision to vaccinate by:
   • Supporting dialogue and community engagement to increase community knowledge and change its perception towards the vaccine;
   • Enhancing social listening and increasing misinformation management activities at all programme levels to address refusal and respond to rumours;
   • Increasing integration and partnership with local and international NGOs, including integrating polio awareness and knowledge within messaging and materials and other frontline tools used for mobilisation and engagement around routine immunisation, maternal health, and/or nutrition;
   • Positioning the polio programme and campaigns as part of a wider set of health initiatives that respond to the realities of life in Afghanistan; and
   • Reducing hesitancy and creating increased support for and involvement in polio campaigns and increasing caregivers' willingness to vaccinate their children.
2. Women and community engagement: building trust and responding to the significant challenges facing the programme by:
   • Sustaining systematic approaches to community engagement, outreach, and mobilisation interventions with caregivers and carefully planned work with influencers and community leaders;
   • Listening and responding to community concerns, gathering insights into perceptions, and creating spaces where communities can be involved in co-creation of solutions to issues affecting vaccination; and
   • Increasing levels of trust and ownership of the polio programme and developing community relationships in which the programme is seen as a resource for more than just administering polio drops.
   The 2023 NEAP and the Adopting a Gender Lens to Improve and Sustain Polio Vaccine Uptake in Afghanistan: Topline Final Report (see Related Summaries, below) make the following recommendations for improving gender participation:
   • Conduct training on gender-related barriers and gender activities among all the partners.
   • Develop messages and activities to promote the role of women and men in eradicating polio in Afghanistan.
   • Carry out follow-up research focusing on social norms analysis.
   • Improve gender mainstreaming in communications and community engagement through training, data collection, materials and messages, gender-sensitive messaging, and gender indicators.
   • Strengthen women's participation in the polio programme through leadership driven, gender sensitive terms of reference and job advertisements and by ensuring there is a strategy for the prevention of and response to sexual exploitation, abuse, and harassment functioning at the community level.
   • Improve gender and security factors affecting women's participation, including for mosque-to-mosque campaigns, by mobilising support from both male and female community members using gender-sensitive and appropriate approaches, working with larger numbers of older women, and advocating continuously for greater female involvement.
3. Substantive integration and partnership building: providing other related services in response to Afghanistan's growing humanitarian needs, thereby enabling the programme to extend its reach, by:
   • Reinforcing the message that the polio programme contributes to a much wider set of community needs;
   • Providing a stronger base for responding to community concerns by creating partnerships that allow for linking communities to other services and knowledge; and
   • Developing educational materials that incorporate polio knowledge and information with that of partners on high priority community health concerns such as routine immunisation and maternal health.
4. Improve evidence generation and knowledge management: gathering evidence on how communities perceive the polio programme, their intent to vaccinate, the barriers they confront, the social norms that influence their actions, and the impact of the various activities and initiatives the programme is engaged in by:
   • Establishing and streamlining a monitoring system to systematically collect evidence to inform programme design and course correction;
   • Building the capacity of UNICEF and partner staff on evidence generation and use of evidence;
   • Conducting a caregivers' survey (baseline, mid-term, and end); and
   • Conducting ongoing rapid assessments using proven social science methods.

In consultation with community groups and polio health workers at the forefront, and based upon an understanding of the local norms, community initiatives will be supported that aim to address the lack of motivation and polio eradication activities fatigue, while making any polio outbreak visible and a national concern. They may include a radio drama series focusing on polio prevention in the context of daily life in communities and families, development of a national/local model to promote polio messages at household and community level, and efforts to promote UNICEF's Aisha character as a means of fighting the poliovirus in Afghanistan.

The programme will implement the 2023-2025 communication strategy and develop context-specific national and subnational communication action plans with participations of all stakeholders. Activities will include:

• Mass media engagement: Polio awareness is critical to the successful implementation of campaigns across the country. Engagement of local mass media will adapt to the current context with its contracted media landscape and economic hardships. The following actions will be taken:
  • Regularly map media to establish functional channels for media engagement and monitoring to ensure consistency in creating polio awareness at national and community level.
  • Revise TV and radio engagement plan and incorporate mapped, functional channels or mass broadcasts of polio messages for nationwide and subnational campaigns. Targeted channels will be selected for case response initiatives.
  • Maintain media monitoring mechanisms to ensure timely broadcast placement and reduction of broadcast drops.
  • Intensify media roundtable discussions and debates at provincial, district, and village levels during campaigns and outside of campaign period to engage and increase community participation in discussions regarding their children's health and polio immunisation concerns. Key panelists will include influencers, including religious leaders, community leaders, and medical experts.
  • Implement media impact assessments for better analysis and planning to achieve the required results.
  • Maintain the production of high-quality multimedia materials to increase polio knowledge and awareness and address programme challenges including missed children, refusals, rumours and misinformation, and other priorities to influence behaviour change towards vaccine uptake.
• Digital media engagement and other innovations: Social media engagement plays a critical role in creating polio awareness as well as informing and educating communities on the importance of vaccination children against polio. Strategic digital media engagement actions will include:
  • Develop a social media strategy and action plan to strengthen digital approaches to increase engagement across all platforms to amplify vaccine acceptance.
  • Target specific regions, especially outbreak areas and high-risk polio circulation provinces and districts, with consistent messaging and engagement to increase awareness.
  • Use various mechanisms and tools for social listening, analyse social media trends, track rumours and misinformation, and design appropriate messages to counter them.
  • Build the capacity of the social media cell at the National EOC and other members of the Communication Working Group on better ways to increase awareness and engagement reach while at the time countering polio rumours and misinformation.
  • Link social media platforms and audiences with U-Report, and provide a toll-free number that relays key polio messages.
  • Use social media engagement to drive traffic on polio free website as the key reference point for all polio programme information and to increase knowledge of polio and routine immunisation.
  • Maintain and regularly update the PEI website with information and updates, eradication strategies, success stories, achievements, challenges, and other relevant information.
  • Localise website content, and ensure all information is easily accessible in the local languages of Pashto and Dari.
• Crisis communication: Support will continue to be provided to Regional EOCs to ensure a crisis communication response protocol is developed and implemented.
• Partnerships and advocacy interventions: The PEI plans to:
  • Continue to build capacity of journalists to better understand polio and vaccines through media training and enhance their reporting skills on polio and health-related issues by strengthening existing partnerships with Radio Azadi and Voice of America (VOA) and building new partnerships with sports associations and other influential organisations to play a critical role in vaccine acceptance.
  • Maintain advocacy with key decision-makers and leadership at national and provincial levels, and involve high level religious scholars and Islamic institutions.
  • Continue to motivate dedicated journalists to produce polio stories addressing vaccine uptake issues, and maintain polio eradication at the top of the news agenda.
• Cross-border communication interventions with Pakistan: Addressing high-risk mobile populations moving between the two countries will mainly entail coordination with the Pakistan programme in several areas:
  • Synchronise communication materials for border crossing points.
  • Map and engage media channels along the border to create polio awareness.
  • Use well known influencers and humanitarian actors on both sides of the border to engage mobile populations and influence towards vaccine acceptance.
  • Initiate social listening along the border to understand rumours and misinformation circulating, and prepare for appropriate response.
  • Coordinate with humanitarian actors providing essential services at the border to integrate polio information packages.
• Islamic Advisory Group (IAG) initiatives: The Communication Working Group will continue to work with IAG members and religious influencers through capacity building and knowledge sharing regarding polio vaccination, routine immunisation, and child health in Islam. The following interventions will be pursued:
  • Continue advocacy meetings with religious leaders, scholars, and mosque imams to: advocate for polio eradication, routine immunisations, and child health; raise community awareness; create demand for vaccination; and tackle refusals based on religious misconceptions.
  • Work with community influencers to support supplementary immunisation activities (SIAs) and facilitate access for campaigns to reach all children through the house-to-house vaccination strategy.
  • Visit madrasas to highlight importance of vaccination and immunisations in Islamic Shariah and to ensure support for polio vaccination campaigns.
  • Build the capacity of national IAG provincial focal points and religious scholars on vaccination, routine immunisation, and mother and child health from an Islamic perspective.
  • Offer religious scholars training on interpersonal communication skills to advocate for polio eradication and routine immunisation, raise community awareness, create demand for vaccination, and tackle refusals based on religious misconceptions.
  • Ensure accountability and impact for religious leaders trained and engaged in the communities to influence and convert vaccine refusals.
  • Revise the Fatwa book under the leadership of the Islamic Emirate of Afghanistan, and ensure that it is certified by the Ministry of Haj Awqaf.
  • Train FLWs on the Fatwa book content for informed discussions during household visits and community meetings.
  • Coordinate with the Ministry of Religious Affairs and Ministry of Education and Higher Education.
  • Orient 2022 Sharia faculties on polio, routine immunisation, and mother and child health - maintaining a data base of trained student for their further engagement to support immunisation and other public health interventions.
  • Disseminate messages on importance of vaccinations and mother and child health from an Islamic perspective through information and educational communications materials and social media.