Days after the self-imposed restrictions on people travelling to and from Pakistan, a clearly defined procedure is yet to be outlined for polio certification, leaving thousands in a state of confusion.

“Where do we go? Should we visit a private hospital or a government facility?” asks Saeed Khan who is gearing up for a family trip to the Middle East. “What if we are turned back from the airport and asked to get a polio certificate from a hospital at the last minute?”

Similar concerns are being voiced by thousands preparing to travel outside the country as summer vacations draw near.

According to statistics from the Prime Minister's Polio Monitoring and Coordination Cell, an average of 28,000 land, sea and air travellers are expected to leave Pakistan per day.

And the answers to their questions are not readily available.

Dawn.com contacted PM focal person on polio Ayesha Raza Farooq, who said a strategy had been outlined to meet the ‘temporary WHO recommendations.’

“Arrangements have been made at tertiary care hospitals where the medical superintendent will vaccinate the traveller and provide a standardised certificate four to six weeks prior to their travel. For emergency travellers, arrangements have been made at the airport. These are all oral vaccines and provided free-of-charge.”

However, information does not seem to have trickled down to the provinces as Sindh’s Deputy Director for the Expanded Immunisation Programme Durrenaz Kazi says “a confirmed strategy is yet to be defined.”

Consequently, most individuals travelling abroad resorted to guidance from private hospitals where they were charged between Rs600 to Rs1,000 for the vaccine, which was injected into those above eight years of age.

The basic cost for the polio vaccine by injection is Rs300 (excluding administrative costs) while the OPV or Oral Vaccine for polio costs Rs15. The numerous anti-polio drives in the country administer the oral vaccine to children under five years of age free of cost.

Presently, it remains undecided how the cost of the extra vaccines will be met.

Farooq said the WHO has given Pakistan until June 1 to implement the restrictions.

According to Farooq, the federal government has reached out to donor agencies but the matter had not been finalised at the time this report was filed.

Then, there is the additional burden of vaccine supply.

The increase in target population for the vaccine will certainly add to the burden and WHO representative and acting in-charge of the health organisation in Pakistan Nima Saeed Abid realises supply could be an issue. He estimates another 14 million doses are required to meet the needs of travellers.

The total number of doses previously required for the 34.6 million target population of children was 300 million. Sindh alone requires an additional 40,000 doses per week, EPI’s Kazi says.

Now faced with the embarrassing situation of international restrictions, the government has little choice but to up the ante and control the ‘export of polio’ from the country before it is mandated to do so.

“The government has accepted the recommendations and plans to fully implement them within 14 days,” Abid says. When asked about the strategies that will be used he adds, “That depends on the government, however, it (the process) should be available for monitoring.”

Also read: WHO puts shackles on Pakistan over polio

But given the diverse range of obstacles they face, does the government have a fool-proof plan to successfully implement WHO’s recommendations?

Detailing the organisation’s expectations in Pakistan’s efforts to eradicate polio, Abid says they will assess two areas. First, that there is no “exportation of the polio virus” for at least six months.

Second, there should be proper documentation detailing a high quality polio eradication campaign.

The recommendations will stay for 12 months and if at that point, Pakistan has successfully contained the virus within its borders, its status will revert to one where ‘vaccination is encouraged’.

Former Director General for the Health Ministry Dr Rashid Jooma, who closely monitors the developments in the endemic country’s polio struggle, believes the WHO is being “unfair to Pakistan and I think they have overdone this and not for very good reasons.”

Officially the accusation is that Pakistan is spreading the virus to Afghanistan and while it is reported that strains on the virus genetically linked to Pakistan have been found in countries which are no longer endemic, the fact of the matter is these are mainly through travellers of land routes, Jooma adds.

The health expert advises strengthening border security and stricter implementation by vaccination camps that were set up by the WHO a few years back. “That should be their focus, not getting after air travellers.”

Also read: What do polio travel restrictions mean for Pakistan?

Meanwhile, high level officials such as Saira Afzal Tarar, are asking for extensions before the WHO restrictions are enforced but have failed to outline a comprehensive plan to tackle the issue. The extension is needed to work out the logistical discrepancies of the strategy, it was announced.

In fact when contacted, the Airport Health Security did not seem too concerned about the polio vaccine requirement.

Speaking on the telephone an official from the department told Dawn.com, “Don’t worry about the certification, it is not an issue. You only require one (certification) for India and Georgia,” he said confidently.

After some persistence, he said the polio vaccine can be administered free-of-charge at the department at the airport after which the traveller would be furnished with a certificate.

The seriousness of the issue that has dominated news headlines for days and continues to cause long queues at private hospitals for the vaccine would appear a pointless endeavour given his nonchalant response to the concerns.

The solution to polio is hardly a paradox, its hinges unequivocally on the success of anti-polio campaigns in Fata, North and South Waziristan, parts of Khyber Pakhtunkhwa and the Pakhtun-centric areas of Karachi.

In fact, all 59 children infected with polio as of May 6 this year are Pakhtuns.

According to officials, accessibility to the high risk districts and Pakhtun households in urban areas remains the main challenge. It is important to mention here that as of July 2012 the Taliban enforced a ban on polio vaccination in North Waziristan.

Even in Karachi, Pakhtun migrants living in Gadap and Baldia hold on to age-old notions against preventative medicine and the misguided belief that vaccinations cause impotency.

Peace talks with the Taliban are unproductive and relying on them to help with the polio campaign is ill-advised.

If one is to objectively analyse the predicament Pakistan finds itself in, there appear to be some inconsistencies with the recommendations.

Also read: Paralysing Pakistan

There is little doubt that Pakistan has had notable success in controlling the spread of polio, managing to limit the number of infected districts. However, there is no doubt that it continues to miserably fail at eradicating the age-old disease from its soil for a few core reasons, which should be the focus rather than cracking-down on air travellers.

So why the potentially year-long scrutiny of Pakistan’s efforts to contain and subsequently eradicate polio?

Pressure to do more and do it fast, seems the only plausible explanation.

But how much can and will Pakistan manage to achieve given: the bureaucratic nature of business in the country, the fight on multiple fronts, the undefined procedure for certification and a lack of decisive strategy to bring uncooperative Pakhtun families into the anti-polio count depends on how well and how soon the government manages to establish its writ.

Till then, Saeed Khan and thousands of others will have to make do with the little information that is available either from private hospitals or airport health departments.