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Navigating Politics: Why Do We Need Consistent Policy Engagement in the GPEI?

In this lecture, Yodi Mahendradhata explains how global disease control programs can be highly political. (Step 3.9)
YODI MAHENDRADHATA: Navigating politics– why do we need consistent policy engagement in the Global Polio Eradication Initiative? Politics, for better or worse, plays a critical role in health affairs. Health policy processes can thus be highly political. Policy processes sometimes involving dense networks of actors and coalitions with competing values and interests, making things more complicated. The national, state, district, and block level have different political actors with different political interests. Here, we see, for example, the organization of the health system in India. Here, you can see the levels of functioning and how deeply complex engagement across the levels and stakeholders can be.
I’m sure many of you, to a certain extent, would see more or less similar complexity when you review organograms of the health system in your own country. Now, in these types of environments, different levels of government may actually not agree on certain issues, interests, and commitment. At the highest political level, it may be in conflict with community needs and the project goals. Differing approaches and strategies may also be adopted by different stakeholders across national, subnational, and district level, especially in decentralized government. So policy engagement in these types of environments requires a collaborative approach. A national policy based on meaningful participations and consensus from stakeholders from national to community level is really, really important.
This has somewhat been achieved in the case of polio eradication. There has been a very steady high-level advocacy with governments at the highest level trickling down to the lowest level. So polio eradication has practically has received the priority that it deserves and the priority that it needs. In the Somali region of Ethiopia, for example, the most important factor for better coverage was people’s trust, people’s trust to religious, tribal, and clan leaders. And they have used this fact to improve vaccination coverage by engaging religious, tribal, and clan leaders to mobilize the community. So lessons from GPEI basically suggests that engaging political and this at many level is key.
This could take form as hosting policy dialogues or stakeholders’ workshops amongst all relevant stakeholders throughout the planning and implementation process. This may also involve holding advocacy meetings at the national, subnational, and district level, keeping priorities and messaging consistent across levels and stakeholders. Here is not a great example of how policy engagement was done for polio eradication. Now, this is a study depicting how Muslim clerics were engaged in a polio eradication initiative in northern Nigeria. Now, at the time, polio eradication initiative was suffering serious setbacks due to vaccination rejection by the Muslim clerics, the imams. However, the intense opposition to polio vaccination was systematically being reversed by the active engagement of imams in areas worst hit by the disease.
A coalition campaign involving imams, Islamic school teachers, traditional rulers, doctors, journalists have been gradually turning the tide against polio vaccination rejection in northern Nigeria. This slide here shows a flowchart for the engagement of imams in a polio eradication initiative, illustrating the different groups that facilitated recruitment of the [INAUDIBLE],, the [INAUDIBLE],, and also the regular [INAUDIBLE] imams into the Polio Eradication Initiative. This is a really nice example of an innovative engagement and coalition campaign at the community level for Polio Eradication Initiative. So I would encourage you to go through the papers cited on this slide for further details. Now, there are often also competing political, economic, and social priorities across government levels, as well as across ruling parties.
Eradication efforts in Afghanistan, for example, have been complicated by civil unrest and insurgent occupation. Political leaders in these conflict-affected areas have faced competing political priorities, balancing politically savvy messaging and other health priorities for the country. The continued war and conflict in Afghanistan have led to health workers’ severe shortage, mainly caused by outmigration, poor and unequal distribution in rural or comparative urban settings. Additionally, while the government has remained supportive of the polio program, high profile endorsement by the government has proven to be counter-productive in areas where anti-government forces may oppose government messaging and harm healthcare workers. For example, the Taliban and other anti-government elements sometimes issued fatwas denouncing vaccination as an American ploy.
Additionally, Taliban insurgency in bordering provinces of Pakistan and Afghanistan have imposed a ban on polio campaigns and targeted healthcare workers. The government [INAUDIBLE] to address issues such as parents refusing to immunize their children because of fear of being targeted by the Taliban, which sees medical teams as a threat to its control in the region. Now, not only are there competing priorities, but there are also variable impacts of implementing a given policy or program. It is important that we view healthcare challenges as multi-sectoral. In widely implementing polio eradication activities, in addition to the existence of fragile health systems and poor infrastructure in many contexts, the lack of holistic policy making has been exposed.
Some communities may be reached only by polio vaccine and not by any other health services. This can lead to discontent and a backlash against the program. So in designing and implementing policies and programs, it becomes imperative to consider other economic, social, and cultural impact as well. Essentially, any policy related to any health issues, whether it’s a disease outbreak or maternal and child health issue, must make a serious attempt to also address many of the other health and non-health outcomes as well. Now, given that politics may create divides in communities, it’s also important for public health programs to maintain neutrality. In Afghanistan, for example, one solution included coordination with different opposition groups to gain access to unsafe areas.
This was call Days of Tranquility, where all parties negotiated a ceasefire in order to allow children to access healthcare. This has contributed to a higher vaccination coverage. The county program maintains constant dialogue with anti-government elements at local, provincial, and higher level to ensure program neutrality for polio eradication and support activities. Believe that polio eradication and government health workers are neutral, both in words and action, has a significant impact in gaining the trust of communities and anti-government elements. Lessons from polio eradication also highlight the importance of anticipating government change. Periodic change in countries’ leadership and management result in changing priorities and policies.
You can do a lot of work getting a government on board, and if they lose an election, you may have to start over at square one. When a new governor came, for example, he might try to bring his own people and friends looking for ways to replace current people in positions. Program fatigue, donor fatigue can also be major issues. Recommitting will and resources to the project every year for a prolonged time period can be really challenging. Therefore, government long-term commitment can be especially important. However, to sustain the commitment of the government, not at the national level only but in every district in itself, is a huge challenge. It’s not a one-time effort. It’s for years.
It’s for decades that you have to sustain them. It requires a lot of commitment and champions at the national level, at the state level– not only in the political environment, but also in an administrative environment. In short, it requires strong and persistent advocacy. There are still many other lessons for policy engagement from polio eradications which are worth highlighting. Let me just share a few more, which I think are quite important. First, transparency and collaboration– in this regard, polio eradication highlights the importance of sharing experiences at the national and regional levels on progress and challenges for maintaining transparency.
Second, participatory planning– there are many case examples from polio eradication which clearly illustrate the importance of involving a wide range of stakeholders at multiple levels in planning all phases and activities of the program. Third, social accountability– experience from polio eradication underlines the importance of utilizing social accountability tools to get feedback from committee members and to improve service delivery and governance. Last but not least, ownership– we can avoid interruptions in public health programs if everyone has a sense of ownership. If people understand at the national level that this is an integrated program, that we are all sitting in the same boat and working for the same common goal.
So in a nutshell, polio eradication provides us with a wealth of lessons on policy engagement, lessons on navigating politics by ensuring consistent policy engagement. This brings us to the importance of engaging stakeholders effectively.

Yodi Mahendradhata, MD, MSc, PhD, FRSPH Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Indonesia

A global disease control program, such as the GPEI, with a vast network of stakeholders can become a highly political affair. Here we outline some of the challenges and unintended outcomes of navigating politics, as well as strategies to address and overcome these barriers.

Once you have completed the lecture, revisit the organogram on slide 2 and at minute-marker 0:20 in the lecture.

Design an organogram for the political dynamics in your own country. Please highlight where complexities, pushes, and pulls are. Then post your organograms in Padlet.

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