GAPS IN THE SYSTEM
Even the monitoring and administration of polio campaign seems to be marred by politics. Currently, the administration and monitoring is undertaken by bureaucratic district administrations, with minimal involvement of qualified staff and monitors from the health department (even though this is done under the WHO’s supervision).
“There are two types of polio workers — those who belong to the health sector and those brought in from other departments,” says Dr Amir Taj of the Provincial Doctors Association. “The field staff from the health department are assigned areas as volunteers. They are, however, not committed to carrying out a vaccination campaign because of poor incentives,” he says. A worker gets 300 rupees to 500 rupees per day, he estimates. And they are sent to areas that are highly insecure, where distances are great and mobility limited.
But Atta clarifies that, “At the district level, the Deputy Commissioner has to ensure vaccination as a state obligation.” Adding that, “Even as he faces refusals, he has to carry out the campaign reaching the target population. If he refuses when faced with community resistance, he can be booked under 3MPO — a law providing for preventive detention and control of persons and publications for reasons connected with public safety, public interest and the maintenance of public order.
Bannu division drew much attention when traders in the region threatened to resist vaccination. Shah Wazir, who announced the boycott, says the act was meant to get the government’s attention to withdraw the unprecedented increase in taxes.
“This has resulted in such flaws in the polio campaign as force and coercion. The community understands this and uses vaccination as a bargaining chip,” says Atta.
In the past, Atta has also questioned the commitment of the previous government, saying their polio-eradication programme was the most neglected. “He forgets that previously, like now, it was the PTI government in power in Khyber Pakhtunkhwa, where the most cases of polio have been reported this year,” says a public health practitioner. “Government transitions shouldn’t affect our commitment because the funding is international and the district coordinators remain even if governments move on.”
Every government over the past two decades has shown its political will and commitment to vaccinations in general and to polio eradication in particular, says Dr Samia Altaf, a public health professional with 40 years of field experience. “What’s missing is the translation of the objectives into actual plans — an overall strategy and implementation plan with committed funding from the government that demonstrates an ownership of the programme,” she says.
“All governments have relied on the donors to fund vaccination drives which, though generous, is always ear-marked for specific activities agreed in advance. They have to be spent on a particular activity, even if later the field situation advises against this use,” she adds.
Atta agrees that Pakistan has to “own the programme as its own.”
“The programme has failed to create demand, while insisting on ‘forced supply’,” he says. He claims that this is going to change. “In our communication strategies in the run-up to the next campaign in December, we are focusing on creating demand [wherein] people can see polio as a health concern.”
ROOM FOR CHANGE
Since 1994, Pakistan’s Expanded Program on Immunization has changed very little in terms of design and implementation. But while the programme has remained largely unchanged, the country, of course, has not. The population has increased, resources have undergone change and skill sets have altered, as have institutions and government systems and the reality of people’s lives. “But when it comes to health, assumptions remain simplistic,” says Dr Altaf. “Taking service delivery programmes to a large scale needs different and context-specific skills that are sorely lacking in the Pakistani health system [that is] trained to treat diseases,” she says.
“Given the recent setbacks in the polio programme, experts advocate the organisation of a well-functioning system of routine vaccinations,” she adds.
This recommendation has been ignored in the past and the polio programme remains vertical in nature — monitored and administered through a highly centralised system at the federal level, when health is a provincial subject. This way of organisation causes confusion, inefficiency and lack of ownership. Like the family planning programme before it, vertical programmes are not well integrated into the primary health system at the district level.
“The financial coverage for primary healthcare is hardly 10 percent of the budget whereas the polio-eradication programme, which remains independent, has 100 percent coverage,” points out anthropologist and development professional Zaigham Khan. “With this neglect, space for all kinds of narratives naturally crops up,” he says. “In the former Fata or parts of Balochistan, where infant mortality is high due to diarrhoea, people fail to see where polio fits in their scheme of concerns.”
Still Atta insists that there is a need to see the bigger picture. “To understand refusals, one has to look at their cause and context,” he says.
“The polio programme was designed to ensure herd or group immunity against a virus. It is not aimed at individual needs. Which is why children have to be covered across the length and breadth of the country through simultaneous vaccination,” he says, adding that, “Pakistan has suffered due to militancy, insurgency and conflict in recent years that has negatively impacted the healthcare environment...
“People don’t know polio vaccination is not a ‘disease control programme’ but one aimed at ‘virus eradication’. It has to focus on a specific area, which is seen as neglect of the general healthcare system that has collapsed for the reasons cited,” he says.
The writer is a Peshawar based journalist
Published in Dawn, EOS, September 29th, 2019