|Polio - The Beginning of the End (WHO, 1997, 113 p.)|
Over the years polio has taken a heavy toll on the lives of both children and adults. Before the development of polio vaccines, about 500 000 people a year were paralysed or died after contracting the disease. In the United States, which endured severe epidemics of polio in 1916 and in the 1940s and 1950s before the development of polio vaccine, this panic-generating disease became known as "the crippler". Today, polio has been eradicated in the Americas and large areas of the world are becoming polio-free, but the disease continues to maim and kill in some of the poorest and most densely populated countries. In addition to the physical suffering involved, polio paralysis can create lifelong dependency and loss of productivity among survivors - placing a heavy burden on the poorest families.
While the humanitarian benefits of global polio eradication will be immeasurable, efforts have been made to quantify the financial savings that can be anticipated. WHO estimates that once polio is eradicated and immunization halted, global savings from immunization, treatment costs, and rehabilitation will amount to over US$ 1.5 billion a year. But there is no way of knowing how much of that money will be redirected to other health programmes.
The reduction in human suffering and death will be felt most in the poorest and least developed countries, where the disease is still endemic. But many of these countries are now also paying an increasing share of the cost of national immunization days - representing a relatively higher proportion of GNP than in the richer industrialized countries. At face value, the financial savings will be greatest in the countries where the costs of polio immunization, treatment, and long-term rehabilitation are highest. The European Union countries, for example, will together save an estimated US$ 333 million a year once polio has been eradicated. In the Netherlands, the cost of controlling the 1991-92 outbreak of polio involving over 70 members of a religious community, amounted to US$ 10 million - without taking into account the long-term costs of hospital care and rehabilitation for the 66 survivors. Meanwhile, in the United States, three years after polio eradication was certified in the Americas, the Government continues to spend over US$ 230 million a year maintaining high levels of routine immunization coverage to prevent the reintroduction of poliovirus from polio-endemic countries. The supply of polio vaccine alone costs over US$ 105 million a year. In addition, the US Government is still contributing towards the costs of treatment and rehabilitation for polio survivors - including many who contracted the disease during the epidemics of the 1940s and 1950s.
The United States will be a major beneficiary once the disease has been eradicated globally and polio immunization can be stopped. And there is a precedent for this. It has been estimated that, ever since the global eradication of smallpox was certified in 1979, the United States - the largest donor - has recouped its entire contribution every 26 days.
The 1993 World Bank Development Report, Investing in Health, estimated that in one year alone - 1968 - the global amount spent on smallpox immunization, quarantine, and treatment was over US$ 300 million - more than the direct financial contributions during the entire 12-year eradication programme. The eradication programme had "saved hundreds of millions of dollars a year in direct, measurable costs, as well as unquantifiable amounts of human suffering. Few investments of any kind generate human and financial benefits on that scale."
In addition to the humanitarian and financial benefits, polio eradication is having a positive impact on health services and on the development of health infrastructures throughout the world. In 1988 when the World Health Assembly resolved to eradicate polio by the year 2000, Member States were determined to ensure that health service provision was strengthened and not neglected at the expense of a "vertical" programme focused on a single disease. The Resolution emphasizes that "eradication efforts should be pursued in ways which strengthen the development of the Expanded Programme on Immunization as a whole, fostering its contribution, in turn, to the development of the health infrastructure and of primary health care."
The World Health Assembly emphasized that global efforts to eradicate polio should also contribute to health infrastructure development and primary health care.
Photo: UNICEF/Maggie Murray-Lee (2983/89)
To what extent have these demands been met? The only formal study carried out so far - by the Taylor Commission - has reported positively on the impact of the polio eradication campaign on health systems in the Americas. However, the Commission's report, published in 1995, pointed out that most countries in the Americas already had a well-organized health system and infrastructure when the polio eradication campaign started. And it cautioned against applying the findings of the report too closely to countries where health services had not yet reached the majority of the population.
Polio eradication has helped raise public awareness of the importance of routine immunization - not just for polio.
The independent commission, established in 1992 by the Pan American Health Organization, based its findings on a sample of six Latin American countries where polio was still occurring at the start of the eradication campaign: Bolivia, Brazil, Colombia, Guatemala, Mexico, and Paraguay. The Commission found that the greatest positive impact of polio eradication was on social mobilization and intersectoral cooperation, twin pillars of primary health care, and two strategies that until then had proved the most difficult to implement.
The social mobilization strategy involved strengthening existing community organizations, the widespread use of education campaigns involving the mass media, and efforts to involve political and community leaders - a joint strategy that has now been successfully adopted by other health programmes both in this region and elsewhere. The approach ensured that communities were not only motivated to bring their children to be immunized during national immunization days, they also became actively involved in the campaign - helping deliver vaccines and maintaining the cold chain, often making available their own vehicles, refrigerators, and ice-boxes. Elsewhere, in the Western Pacific Region, NIDs carried out in the Philippines from 1993 to 1996 were heavily supported by the business community. More than 150 businesses provided funding, and immunization posts were established in over 150 fast-food outlets, over 400 petrol stations, and hundreds of company clinics. Children were immunized in shopping malls, radio and television stations, bus and railway stations, government offices, and schools.
The Taylor Report also maintained that the eradication campaign had established a "culture of immunization", and improved communications between health services staff and local communities. In the Americas, and elsewhere, polio eradication has helped raise public awareness of the importance of routine immunization - not just for polio. In the Western Pacific Region, for example, where national and sub-national immunization days were carried out in polio-endemic countries from 1991 to 1994, there was a marked increase in routine immunization coverage with other EPI vaccines. In the polio-endemic countries with the lowest immunization rates in the region - Cambodia and Laos - immunization coverage with BCG, DTP, and measles vaccine increased by 30% and 100% respectively. In Laos, BCG coverage rose from 26% to 69% between 1990 and 1994, DTP coverage from 18% to 48%, and measles coverage from 32% to 73%. (See Annex.)
In addition, national immunization days for polio, particularly those involving negotiated ceasefires, have often included other vaccines and nutrients as well - most commonly measles and vitamin A for children, and tetanus toxoid for women of childbearing age. During NIDs in Myanmar and Nepal, posters were used to inform parents of the need for routine childhood immunization against other diseases. In Iran, routine immunization cards were checked and, where necessary, children were referred to other health services.
Together with the upsurge in immunization against other diseases, there has been a marked increase in the proportion of EPI vaccines paid for out of national resources, and a corresponding drop in the amount of donor support needed for vaccines for routine immunization. This trend has been actively promoted by UNICEF and WHO in all countries in an effort to ensure that all but the poorest countries are self-sufficient in vaccines. The successful eradication of polio in the Americas helped raise the profile of childhood immunization and helped motivate governments to take on a greater share of vaccine costs. By 1995 the bulk of vaccine costs were being met by governments throughout the Americas region. Requests for external assistance for vaccine purchase were 25% lower for the five-year period 1992-1996 than in the previous five-year period. In Guatemala, vaccine self-sufficiency surged from below 5% in 1990 to 100% within five years, and in Nicaragua from zero to almost 80% over the same period. In the Philippines, following the successful NIDs in 1993, the government almost tripled its vaccine budget, making vaccine a regular budget line item from then on.
National immunization days for polio have often included other vaccines such as measles.
The Taylor Report maintained that the polio eradication campaign in the Americas had played a key role in demonstrating new approaches to health service delivery. Other programmes had been encouraged to adopt its inter-agency and intersectoral cooperation strategies, media strategies, information systems, surveillance systems, and evaluation methods. The development of polio surveillance systems, for example, has already been used to help combat other diseases including measles, neonatal tetanus, and cholera. During the cholera epidemic in Peru in 1991, the surveillance system that had been built up to support polio eradication proved invaluable in efforts to ensure rapid reporting of suspected cholera cases. "It is very likely," the Taylor Report pointed out, "that the health systems of the Americas would not have had the capability to respond as they did to the cholera epidemic without the EPI/Polio experience."
In the Americas, where governments are now committed to eliminating measles by the year 2000, the surveillance and laboratory system established during the polio eradication campaign is now being used to monitor and detect measles cases as well. Meanwhile, in Egypt, from 1992, reporting of neonatal tetanus cases has been successfully linked to the surveillance system for acute flaccid paralysis. The system has also helped promote case investigation skills and target immunization to unreached populations - providing access to routine immunization services as well.
The Taylor Report also noted that the polio eradication programme developed management strategies and systems that could be readily transferred to the delivery of other health services. These management strategies "worked and contributed to other programs, either by sharing them or setting the example and becoming a model to learn from". A key element in the campaign strategy was the establishment in 1985 of an Interagency Coordinating Committee (ICC) to draw up a regional plan of action. Membership included the Pan American Health Organization, the Inter-American Development Bank, Rotary International, UNICEF, USAID, and (from 1987) the Canadian Public Health Association. In addition, national Interagency Coordinating Committees were established in every country under the leadership of Ministries of Health to develop five-year plans of action for polio eradication. All countries now prepare annual and five-yearly national plans of action with clearly defined objectives, activities, costings, and identified sources of funding. This has resulted in improved health planning, and monitoring and evaluation of the implementation of health programmes. The Interagency Coordinating Committees have now extended their remit to include other aspects of maternal and child health - especially the goals of the 1990 World Summit for Children - and helped boost the efficiency of funding health initiatives.
Even the poorest countries are making a sizeable contribution to the cost of polio eradication.
An additional benefit is that the development of logistical support for polio eradication - transport and communication systems, and the cold chain, for example - can be used for other primary health care needs. And the development of new technologies - vaccine vial monitors, for example - can be used in efforts to combat other diseases as well.
Not all the responses obtained in interviews by the Taylor Commission were positive. A major criticism was that both funds and personnel were being diverted to polio eradication while other programmes competed for scarce resources - one of the most frequently voiced criticisms of eradication programmes. But is it true?
In the Americas, about 80% of the cost of polio eradication was met by national governments. Elsewhere, even the poorest countries, which rely heavily on donor support, are making a sizeable contribution to the cost of polio eradication. But many of these costs are in the form of opportunity costs, not direct financial contributions. They include regular staff salaries, maintenance, transport costs, or assistance from the military. And while it is clear that external funds for polio eradication could have been used for other health programmes, there is little evidence to suggest that this level of funding would otherwise have been available. Donor funding for polio eradication is not necessarily money that was earmarked for spending on health. Rotary International - the largest single donor - brought substantial private sector resources and volunteer manpower into the health sector for the first time. The US$ 400 million donation over 20 years is the largest single contribution ever from the private sector for a public health programme. Other agencies and donor governments have made similar long-term commitments to polio eradication. But this level of funding is easier to obtain for global campaigns like polio eradication that are time-limited and have a proven track record of success than for routine open-ended health programmes.
Other complaints included the failure to integrate polio eradication with other health programmes, and concern that door-to-door immunization might establish a paternalistic attitude to health services and reduce attendance in health centres. Meanwhile, in some of the poorest and least developed areas in Colombia, Mexico, and Brazil, there were reports of resistance to immunization due to repeated home visits to immunize children.
Despite these and other such criticisms, the polio eradication initiative is clearly making a major contribution to health systems in the way envisaged by the World Health Assembly in 1988. The eradication strategy embraces all five principles of primary health care: equitable distribution of resources, community involvement, a focus on prevention, the use of appropriate technology (introduction of vaccine vial monitors, for example), and a multisectoral approach.
Meanwhile other areas within the Expanded Programme on Immunization and other health programmes as well have been strengthened as a result of new, innovative approaches to health service delivery. Polio eradication has helped raise the profile of the public health sector and created a renewed demand for immunization that has resulted in higher immunization coverage with other vaccines.
Far from poaching scarce resources, polio eradication has helped pinpoint gaps and weaknesses in health service provision and in many cases helped to fill these gaps. These include a strengthened cold chain, improved management capacity, strategies for social mobilization and intersectoral cooperation, the development of disease surveillance systems, improved communications systems, and the ability to target and reach entire populations. And like the smallpox eradication campaign before it, global efforts to eradicate polio have succeeded in bringing health services to some of the most under-served populations in the world - including children trapped inside war zones.
Other benefits are less tangible but equally important. In some of the least developed countries, routine health services have been revitalized through the focus on polio eradication. And through their ability to organize immunization campaigns on such a vast scale, governments have acquired the will and capacity to tackle other public health problems as well - measles, in the Americas, for example.
Meanwhile, health workers throughout the world have been motivated by achievements in their own countries and elsewhere.
In peacetime, there are few humanitarian efforts that can fire the imagination and unite people around the globe. Polio eradication is one of these. WHO has succeeded in bringing together an unprecedented range of contributors: governments throughout the world, other UN agencies, non-governmental organizations, community groups, the business community, religious organizations, and many others from both the public and private sector. When polio is eradicated, future generations will be heavily indebted to all those who over the years have helped ensure that they could inherit a world without polio.