Was it Amitabh Bachchan? Understanding India’s success with Polio Elimination

As the world gears up to rollout the Covid-19 vaccine, we revisited our learnings from studying a successful immunization program in India. 

Polio eradication strategy was a global one, driven by powerful stakeholders from the developed world. The Government of India, in aligning with the global goal for Polio elimination, concentrated mainly on creating the infrastructure for effective delivery of vaccines. It did not anticipate the ensuing resistance to vaccination in certain high-risk local communities. The rates of refusal to take the vaccine were high. Many rumors about the side effects of the vaccine floated in certain communities. 

Experts believed that India would be the last country to eliminate Polio. Its high density of population, poor sanitation, high birth rate, low rate of routine immunisation, widespread diarrhoea, hard to reach terrains, high migration rates and resistance to vaccination among some communities seemed like unsurmountable challenges. Sixty percent of all global polio cases were from India, as recently as in 2009.

India surprised the experts when it was officially declared Polio free in 2014. Key to this success was the Polio immunization program. What made the immunization program finally succeed in India?

We studied the Polio campaign closely for a project. Stakeholders, on the ground, highlighted a few factors that were instrumental in making Polio elimination a possibility.

Powerful agencies setting the agenda and organising resources

Inter-sectoral collaborationsInter-sectoral collaborations

The success of the Polio campaign can be attributed to the seamless partnerships between WHO for technical expertise, Rotary International for advocacy, USAID for funding, Government for operationalizing the strategy, Private Sector for enabling networks, and UNICEF and CORE for social mobilisation. All the partners worked with a spirit of openness and transparency which is difficult to find in programs of such scale involving multiple stakeholders. Government played the pivotal role anchoring inter-sectoral partners and stayed committed to Polio elimination in India. Departing from its usual manner of functioning, the government was accepting of feedback from all partners in every instance.

Polio campaign review at local levels

Role clarity and accountability

All partners worked with clear mandates and role clarity – while Rotary made concerted efforts on advocacy, WHO was responsible for surveillance and UNICEF & CORE handled social mobilization. There was accountability embedded in the framework of engagement with responsibilities clearly articulated at all levels, mechanisms to take corrective actions were established early on – the structure and processes of the task forces at national, state, district and block levels were key to establishing accountability as well as smooth functioning and coordination between partners in the entire Polio campaign. Strong, cohesive and structured monitoring was key driver that fueled the progress of the Polio Project in India. 

Cold chain infrastructure

Built immunisation infrastructure

The cold chain systems and infrastructure that were setup for Polio project will be used for Routine Immunisation, the next goal for the government. The government is now able to make quick plans without huge investments and absorb new immunizations that use the existing cold chain infrastructure. 

Door to door campaign

Reaching out to communities

Global strategy, when implemented as is in India, met with unexpected resistance in certain communities. Players like UNICEF India and CORE played the critical role of communicating with local communities on the ground through interpersonal relationships, influencers, media and print channels. This gave impetus to the campaign, which was receiving a lot of resistance in high-risk areas. 

Granular household mapping for vaccine surveillance

Creating detailed databases

The project faced significant communication challenges in the field with high refusal rates and rumours that could have impacted it adversely. Civil society organisations were critical in mobilizing communities – collecting base line data in High Risk Areas and households with children under the age of five. They created the database of under-fives, new-borns, migratory children as well as families that were resisting the Polio vaccine. There were many kinds of resistances – some were to negotiate with the government for better services in their local communities while others were due to beliefs and myths associated with the Polio vaccine. The granularity of the data helped identify appropriate matches of influencers to families refusing vaccination.

As the Polio experience has demonstrated, releasing an effective vaccine is only a part of successful mass immunisation program. Perhaps, it is time to think of Covid-19 vaccination as more than just successfully formulating a vaccine. A successful immunization program, such as for Polio, needed focus, intent, resources and collaboration between multiple stakeholders.

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