MEETING REPORT

POLIO ERADICATION AND TRANSITION: IDENTIFYING LESSONS FOR

FUMI KURIHARA, STEPHEN A. MATLIN

INTRODUCTION The world marked a historic milestone on 24 Geneva, hosted a high-level panel October 2019: wild type 3 (WPV3) discussion in Berlin at the World Health was certified as globally eradicated. 1 Summit. The event critically reflected on the Following the eradication of WPV2 in 2016, key lessons drawn from the eradication WPV3 is the second of the three types of programme, explored how these lessons can WPVs to have been eradicated. However, be best used for the benefit of national health worldwide is far from over, systems and global health, and assessed the as several challenges remain to be wider implications of both polio eradication addressed and resolved. and transition for global health. This report elucidates key messages drawn from the On 27 October 2019, the Global Health event. Centre (GHC) at the Graduate Institute of

Bernhard Schwartländer, Chef de Cabinet at the World Health Organization CHALLENGES TO POLIO ERADICATION AND TRANSITION: LESSONS FOR GLOBAL HEALTH

TACKLING CVDPVS – CAN THE important to keep in mind that the OPV and INTERNATIONAL COMMUNITY WIN THE IPV must be used in combination – whilst IPV “RACE AGAINST TIME”? strengthens the and Although the recent eradication of WPV3 provides protection from polio, OPV is the deserves celebrating, other strands of main preventive measure against polio. Third, persist and must be addressed in addition to these technical aspects, the urgently. In addition to prevailing WPV1 introduction of nOPV2 needs to be cases in and , 2 all accompanied by a carefully planned and panellists expressed their concern regarding executed communication strategy. Since the increasing incidence of circulating hesitancy is fuelled by anti- vaccine-derived polioviruses (cVDPVs). In narratives and mistrust in public 2019, approximately 100 cases of cVDPVs authorities, both in polio- and non- were reported across and . 3 endemic communities, the introduction of Bernhard Schwartländer, Chef de Cabinet at nOPV2 needs to account for this challenge the WHO, noted the alarming possibility of as it will otherwise further complicate the the current vaccine- inducing outbreaks vaccination of children. taking the nature of a WPV outbreak. In addition to these criteria, panellists voiced The Oral (OPV) can lead to their concerns regarding certain outbreaks of vaccine-derived polioviruses. manufacturers’ reluctance to produce the OPVs contain - new due to fear of accidental which replicate in a person’s intestines for a contamination, which could ultimately lead to limited period to help the body develop another epidemic. against the virus. As the vaccine- virus is excreted during this period, it can In other words, as Bernhard Schwartländer spread within under-immunized communities noted, “they [the vaccine manufacturers] do and can undergo genetic changes, which can not want to be the ones who take the risk for turn into a polio-form that paralyzes children. the world.” Stephen Sosler, To tackle cVDPVs, a more genetically stable Technical Advisor at Gavi, underscored how attenuated vaccine-virus has been these issues require a dialogue centered on developed and is currently undergoing the fact that manufacturing of vaccines is a clinical trials. This novel OPV2 (nOPV2), global public good. Bernhard Schwartländer developed by Bio Farma in Indonesia, is indicated that fighting cVDPVs is a “race planned for release in June 2020. against time” as these strains of polioviruses need to be eradicated within the 2019-2023 Whilst the nOPV2 does present a new Strategic Plan period. Yet, these efforts are opportunity, panellists warned that its slowed down by structural factors pertinent to implementation must be carefully planned. the production of novel vaccines. To be successful, it must fulfill three criteria. First, effective mechanisms are needed to These experiences, albeit being polio- ensure enough doses of nOPV2 are available specific, hold important lessons for global in the stockpile which can be quickly released. health initiatives in general. On the one hand, Second, the planning of specific campaigns eradication of viruses circulating ‘naturally’ is required. These campaigns must needs to be accompanied by continued coordinate the release of the nOPV2 in monitoring of vaccine-induced outbreaks and parallel with existing campaigns with efforts to improve existing vaccines. If global vaccines that are currently available, such as health actors forego such activities, they do the Inactivated Polio Vaccines (IPVs). It is not only endanger the success of their

2 individual eradication campaign, but also risk for the development, production, and that communities lose trust in public distribution of improved vaccines. authorities and health actors. On the other Addressing these issues is a task for the hand, it demonstrates that the global health global health community as a whole. community needs to create an infrastructure

POLIO TRANSITION-PLANNING THROUGH THE EYES OF GAVI – TOP DOWN AND UNREALISTIC? The governance structure of the GPEI has supporter at country level is unrealistic. The remained flexible over the course of its Gavi Board may have agreed to support the activities. This allowed the multi-stakeholder diminishing polio support at country level in a initiative to address emerging issues and time-limited manner. However, Gavi does not challenges through changes in its way of have the resources to support countries such operation. One of the recent challenges is the as Sudan, and Chad, whose entire planning for polio transition, which includes primary health care network is essentially the integration of polio-assets into wider built with the polio infrastructure. He warned national health systems. To this end, in that whilst is a “gold standard model” in addition to other considerations, Gavi, the terms of having successfully eradicated polio Vaccine Alliance, recently became a member in 2014, it is also “a cautionary tale of what of the Polio Oversight Board (POB). Since other countries are going to go through.” In then, Gavi has increasingly been contributing India, the process of transitioning polio to the GPEI governing structures, including resources into federal and/or state budgets technical and review bodies. has been extremely slow. Hence, it is far from realistic to assume that Gavi’s support over a As a new member, Gavi is able to provide short period of time is sufficient to ensure fresh perspectives on the work of the GPEI. effective transition. These concerns are According to Stephen Sosler, the main aggravated in countries where governments synergy between the work of Gavi and the are facing much wider and more difficult GPEI lies in planning and coordination at the challenges than in India. country level. Gavi has significant health systems strengthening (HSS) resources This experience can inform the global health available in the polio transitioning countries. community concerning two key aspects. First, However, until today, these are not the inclusion of actors who have previously necessarily being used complementarily with been outside of governing bodies can provide the available polio resources. Hence, Gavi not only technical expertise, but also fresh tries to pull the polio transition planning perspectives on the modus operandi of an efforts in this direction. However, Stephen initiative. If global health initiatives are open Sosler observed that the plans currently toward such perspectives, it can ultimately being developed by the GPEI are “way too improve their performance. Second, the top-down driven” without properly unpacking cooperation with specialized agencies, such which essential polio functions are required as Gavi, can increase the complementarity of once polio transmission stops. activities on the country level. However, global health initiatives should realistically Stephen Sosler further noted that the idea of assess the capacities of such agencies to Gavi acting as a short-term transition deliver tasks beyond their specific portfolio.

3 India is a bit of a gold standard model but (also) a cautionary tale of what “ other countries are going to go through. ”

Stephen Sosler, Immunization Technical Advisor in Vaccine Implementation at Gavi, the Vaccine Alliance

VERTICAL PROGRAMMES – UNFIT FOR raising 50 million dollars every year until 2023. SUSTAINABLE FUNDING? However, she pointed out that maintaining awareness and commitments amongst The New Polio Endgame Strategy 2019- donors, even within Rotary, has become 2023 estimates an additional 4.2 billion USD increasingly difficult, especially with regard to is required to achieve polio eradication and cVDPVs. She further noted that Rotary certification, of which the GPEI must raise International does not see itself in a position 3.27 billion USD. On 19 November 2019, the to play a particular role during the transition GPEI had its most recent pledging event in phase. Instead, they see transition as the Abu Dhabi, where donors pledged 2.6 billion primary responsibility of the respective USD, remaining almost 1 billion USD short of governments. the actual target. The pledging coincided with similar processes in other major global health The example of polio demonstrates the initiatives, namely the Sixth Global Fund challenge of vertical funding streams for the Replenishment which raised 14 billion USD operation of organizations when an in October 20194 and the Gavi replenishment eradication campaign comes to an end. As that is set to take place in June 2020.5 This approximately 20% of the WHO’s budget in illustrates how it has become increasingly the biennium 2018-2019 came from the GPEI, difficult to secure funding for health-related the WHO is placed in a critical financial programmes given the competitive funding situation. 6 Against this background , landscape with various organizations Bernhard Schwartländer affirmed that the competing for the same donors. WHO is beginning to negotiate with current and new donors to ensure current resources Judith Diment, Chair of the Polio Eradication do not disappear during the post-eradication Advocacy Taskforce at Rotary International, and transition phase of polio. noted that Rotary International intends on

4 The question of funding after eradication and spurs a re-invention of the primary health during the transition phase of a programme care agenda. Hence, it is necessary, illuminates a larger global health issue, amongst others, to explore how one can namely of vertical programmes and their adjust the motivations and preferences of funding mechanisms. Donors do not see different actors, including citizens, politicians, building health systems as their responsibility. governments, and donors, to contemporary As echoed by Rotary International, they needs. This will require donors to accept perceive this as the responsibility of the different types of funding streams and move respective governments. Instead, donors are away from replenishment processes if global motivated by the idea of ending specific health institutions are to build and strengthen diseases and measuring impacts. Ilona health systems. Kickbusch asserted that the objective of UHC

Judith Diment, Chair of Polio Eradication Advocacy Task Force at Rotary International

MOVING FORWARD This report demonstrates that the polio an option”. As Judith Diment noted, the experience provides valuable lessons for global health community has benefited from global health, particularly with regards to an estimated 27 billion USD through the vaccines, the inclusion of specialized investments in polio eradication. Should polio agencies, and the implications of vertical be eradicated worldwide, this number will rise funding mechanisms. Against this to 40-50 billion USD by 2035. 7 However, background, the discussions at the World were the programme to shift from an Health Summit identified several points eradication to a control programme, WHO which need to be taken into account. has projected that 200,000 children would be victims of polio within the next ten years, Panellists expressed their great which would be an unacceptable outcome. determination and commitment to ending Furthermore, Stephen Sosler, underlining the polio with the statement that “Failure is not importance of polio eradication for Gavi’s

5 work, claimed that “(i)f we do fail in our effort vaccines; discussions on governance, to eradicate polio, there will be serious transitioning, and sustainable funding; and consequences for the entire global health reflections on the shift from vertical disease agenda, global health community, and for programmes to horizontal programmes countries that will experience resurgences of supporting health systems as a whole. As polio.” Ilona Kickbush underscored, “any of you active in global health should be interested in The GPEI embarked with the objective of this agenda”. In other words, “polio is, or eradicating polio, which remains at the top of should be, everyone’s business”. its agenda for the reasons elaborated above. However, panellists stressed that eradication Yet, the polio event and discussions at the is not sufficient for the GPEI to be a success. World Health Summit in general Instead, it is necessary to “finish the job in demonstrated that such discussions are the right way”. The polio programme has largely absent. Not only did few participants been stalling over the last few years. Stephen know about the implications of post-polio Matlin, Senior Fellow at the GHC, suggested eradication adjustments for the wider global that we must take advantage of this period to health landscape, but there was overall very reflect upon the programme. The polio little engagement between the polio community must not repeat the mistakes community and the wider global health made after the eradication of smallpox in community. Perhaps the only disease- 1980, when “eradicationists” rapidly moved specific programmes which gained attention forward to the next disease without fully at the Summit were on HIV/AIDS, absorbing all the lessons available. It would tuberculosis and . The fact that polio be a great loss if the polio programme were stands on its own reveals the consequences to make the same mistake. of a vertical programme that has been For the GPEI to have a lasting legacy beyond working in its own silo for many years. It is polio eradication and transition, it needs to now time for the global health community to hold difficult discussions and connect these start expanding their relationships across to the wider global health landscape. These vertical programmes to enable mutual include, amongst others, debates around the exchanges and learning. responsibility of securing the availability of

If anything, I wish more people “ would recognize that, as we discuss polio, we’re discussing critical issues of global health in general… any of you active in global health should be interested in this agenda. ”

Ilona Kickbusch, Chair of International Advisory Board at the Global Health Centre, the Graduate Institute, Geneva 6 CITATION OF THIS REPORT Kurihara, F., and Matlin, S.A. Polio eradication: lessons for global health. Meeting report. Geneva: Global Health Centre, the Graduate Institute of International and Development Studies. Published November 2019. Photo credit: GHC/World Health Summit.

REFERENCES

1. GPEI: WHO DG – thank you to all who made WPV3-Free World Possible. 25 Oct. 2019. http://polioeradication.org/news-post/day-after-wpv3-declared-as-eradicated-who-dg-thanks-all-stakeholders-who- made-this-possible/ 2. As of 30 October 2019, 96 cases of WPVs have been reported. Taken from GPEI: Polio this week as of 30 October 2019. http://polioeradication.org/polio-today/polio-now/this-week/ 3. Ibid. 4. Global Fund : USD 14 billion to step up the fight against the epidemics. 10 Oct. 2019. https://www.theglobalfund.org/en/specials/2019-10-09-global-fund-sixth-replenishment-conference/ 5. Gavi: UK to host Gavi replenishment in 2020. 13 Feb. 2019. https://www.gavi.org/library/news/statements/2019/uk- to-host--replenishment-in-2020/ 6. WHO: Budget and finance. https://www.who.int/polio-transition/budget-finance/en/ 7. GPEI: Economic analysis of the Global Polio Eradication Initiative. 22 Nov. 2010. http://polioeradication.org/wp- content/uploads/2010/11/VaccineStudyFactSheet_20101122.pdf

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