Challenges and Reorganization

SVEA CLOSSER: So now that we’ve gone over the major actors in the Global Polio Eradication Initiative, we’re going to turn our focus to some challenges. And there were a few major challenges due to the structure of the alliance that became clear in the early 2000s. So as you may remember, polio eradication was supposed to be achieved by the year 2000, but this didn’t happen. In retrospect, this was probably never that realistic, since much of sub-Saharan Africa and South Asia did not even start vaccination campaigns until the late ’90s. But this map shows that in much of sub-Saharan Africa and South Asia, there were still polio cases in the year 2000.

Part of the challenge was that the partners, although they did have defined roles as we discussed in the last lecture, weren’t always completely clear about who was supposed to be doing what. In 2003 and 2004, there was extensive conversation about this and, in addition, a letter clarifying roles. And a global-level policymaker said, quote, “This letter has given the immense impact at the ground level, and we have divided our role.” End quote. And this was really helpful. While the role clarification helped, there were still issues. For example, the WHO, from the perspective of other partners, wanted control over the program.

Whether or not that’s true, there was certainly a degree of opacity within the WHO structure, and they had a command-control-mentality where they often told other people what was going to happen. This influenced how decisions were made both regionally and nationally and led to what some have described as organizational dysfunction within the Global Polio Eradication Initiative.

The image here is from the Independent Monitoring Board for polio, which we’ll talk about in a moment, but they’re trying to encourage the partners to keep in their lane, more or less, that each of these organizations have something they’re supposed to be doing, that they should specialize in it, focus on it, and build their expertise on that, rather than all of them trying to control everything. So there was a second set of challenges that became very clear in the early 2000s, and this is a set of challenges about what we’re going to call parallelism.

And this means that in places with the weakest health systems, health systems that were not set up to provide really maybe any services, or certainly not quality services, the Global Polio Eradication Initiative built their own system, staffed largely by WHO and UNICEF, to carry out key tasks like surveillance, and monitoring, and evaluation that governments did not have the capacity to do. This was a short-term gain strategy. They felt that it was too long term and too difficult to try to build health systems everywhere in the world. And so to try to eradicate polio, they built what they needed to do to get the job done. But this meant that weak health systems were bypassed rather than strengthened.

It was a strategy that seemed effective in the short term, but it meant that government staff often felt that polio eradication was a WHO and UNICEF program, which, in fact, in practice, it often was. So in the year 2000, routine immunization coverage was low across much of the world. So in this chart, all of the lightest color blue countries had lower than 40% immunization coverage in the year 2000. So you can see that much of sub-Saharan Africa, fewer than 40% of kids were being fully immunized. This meant it was a huge lift to fill that gap with campaigns with polio vaccine.

Yet the parallel structure of the polio program meant that these issues about poor routine immunization were not really being addressed. So by the mid-2000s, these organizational issues had led to repeated missed deadlines, which became a major problem for the program. Some major bilateral donors felt they had been misled and funding was beginning to dry up. This map shows how widespread polio was in 2007, including massive outbreaks in northern India and northern Nigeria. So as you can see, there’s polio cases across much of sub-Saharan Africa, and pretty much Afghanistan, Pakistan, India are all polio endemic. So polio eradication leadership initially responded to these challenges by simply pushing back the goal end date year by year.

So the goal of polio eradication was announced to be 2005, and then 2006, and then 2007, and then 2008, and none of those goals were met. So optimistic projections that were repeatedly not met made donors very nervous. And this points to the need to dynamically adapt goals based on analysis of reality and not what you wish would happen, something that many observers felt was not going on in the mid-2000s. Adding to this were the challenges in the global alliance we just discussed. So in the mid-2000s, the reticence of some traditional donors to keep giving to polio eradication paved the way for a new donor, the Gates Foundation.

The Bill and Melinda Gates Foundation, like Rotary International before it, was seeking a champion cause, but they had a different ethos and different principles than other partners. And this further exacerbated some of the organizational tensions that had been ongoing previously. But this graph shows the money available for polio eradication year by year. As you can see, there wasn’t much money at all given to the project until the very late ’90s. In the early 2000s, donations increased a lot with the effort to try to finally get rid of polio. And then the yellow bars at the bottom of the image, which are mostly Gates Foundation money, led to an increase in the overall budget around 2010.

However, this infusion of cash did not lead to a quick end of polio. Compare this budget, over $1 billion a year, with the optimistic projections about the cost of polio eradication in the early years and the very low levels of funding in the ’90s, despite the fact that polio eradication was declared as a goal by the World Health Assembly back in 1988. So at this point around 2010, we have yet another actor, the Independent Monitoring Board. Throughout its 25-year history, the Global Polio Eradication Initiative has established and disbanded a number of boards, advisory groups, and committees to provide expertise and advice to the program.

The Independent Monitoring Board is the first truly independent group charged with assessing the program’s progress, strengths, and weaknesses, and it was created in response to a feeling by donors that perhaps they were not getting the full story or that perhaps an external board would be helpful. The Independent Monitoring Board was established at a critical time, after a difficult decade in which the incidence of polio remained more or less unchanged, despite considerable effort and investment. In 2010, the program resolved to break the deadlock and finally complete eradication. Establishing the IMB was part of its plan to do so.

The concept of an IMB, or Independent Monitoring Board, is innovative, with no clear analog in the history either of polio eradication or in any other global health program. The IMB is a truly independent board established to evaluate and advise polio eradication. It holds meetings about once a year and releases a report. And these reports are, unlike most reports issued by global health organizations, truly interesting and revealing reading. They’re full of provocative graphics and ideas. The IMB gives recommendations and attempts to ensure accountability. Ultimately, it has no real teeth, but it does have shaming power, and its recommendations are generally taken seriously. The IMB paved the way for major reforms in polio eradication after 2010.

A global policymaker commented, quote, “There were just a few people in WHO who were making all of the decisions. And for many years, that command-and-control structure was very effective, worked very well, but then the program stalled. We had to do a full reorganization and reset so that there was a shared decision making. How do you superimpose that on an operational structure that was setup for command and control? And so that was very confusing for our field managers, for our regional managers, country managers. They felt that there were too many cooks in the kitchen making decisions.” So while these changes were necessary, they were also not exactly straightforward.

Today, the Global Polio Eradication Initiative operates on a decentralized, equal partnership model with shared decision making and delineated responsibilities drawing on each partners’ strengths. A global policymaker said, quote, “After that, it was more of a true partnership established and sort of those management groups that, you know, provided a forum for discussions of the strategies and oversight of implementation. I think it was probably the realization that alone, WHO could not achieve it and needed true partnership to deliver on eradication. And the partners said, yes, we would want to be true partners, but then we would also need to be associated with the decision making.

So it was redesigned in a way where all partners had a possibility of voicing their concerns and putting things on the table, so that one agency alone could not make all of the decisions.” End quote. So of course, there are pros and cons of a centralized leadership versus more of a partnership, as no doubt you’ve experienced in your own work. But for polio eradication, it’s widely agreed by our interviewees that it was a positive change to move to a more partnership model. Although the Global Polio Eradication Initiative had been a partnership on paper since the beginning, it hadn’t always operated that way.

A global policymaker said, quote, “For example, in Borno, Nigeria, in 2015 and 2016, we realized that the surveillance data that was coming out of Borno wasn’t accurately geotagged. I’m going to be super candid, we all trusted WHO to report things effectively, and we realized it wasn’t happening, and so that’s an example of CDC in particular stepping in and saying, wait, what needs to happen here to make this work properly? So that’s also kind of a check and balance thing, which I really appreciate about the partnership.” End quote. And the point here is not that WHO, in general, wasn’t doing a good job. They were doing amazing things in many places.

But that allowing different partners to have more weight and more checks and balances was really positive for the program, in general. However, with the addition of more partners and more shared decision making, understanding the structure of the Global Polio Eradication Initiative and how decisions were made was really complicated. So this particular image is from the Independent Monitoring Board’s eighth report, and I’m not even going to attempt to make my way all the way through it. But as you can see, there are a huge number of different agencies, partners, committees, all tasked with making various decisions in various ways.

So the World Health Assembly, which is a meeting of governments, provides the highest level of governance for the GPEI, at least in theory. It issues resolutions that determine the scope and direction for the initiative, and it secures the commitment of the WHO member states. But the World Health Assembly meets only for a few days each year and has many agenda items. In practice, it tends to rubber stamp what WHO advises. So then the next level down in this chart we have the partners, WHO, Rotary, CDC, the Gates Foundation, and UNICEF. Then in addition, more layers below that, we have the Polio Oversight Board and the Polio Steering Committee, which have been created to bring all those partners together.

And then a bunch of different advisory groups cutting across these, and this is even before governments get involved. So the cost of all of this organizational complexity is that good ideas often take a long time before they actually get implemented. A global level policymaker said, quote, “There’s probably an opportunity cost associated with the partnership and the amount of conference calls, and meetings, and discussions, and partners that we need to have, which possibly sort of affects our ability to move faster. But I think that weighing the pros and cons, we still feel that this is the way it needs to work.” End quote. So this image is from the Independent Monitoring Board in 2016.

It shows that there was a gap of 29 months between the idea that combining oral and injectable polio vaccine would be a good thing and when that was actually done in a Kenyan refugee camp, and a gap of 18 months between the idea that mandatory vaccination before travel would be a good idea and when the WHO actually recommended that. So this is, in many ways, a result of the bureaucracy of implementing these recommendations.