Navigating Complexity: Adapting to New Challenges on the Journey to a Polio-Free World

"The COVID-19 work of the Polio Programme has opened up insights and opportunities as to how some of the goals of polio transition (e.g. integrated service delivery) can be achieved more rapidly or in new ways."

The Transition Independent Monitoring Board (TIMB) was created in 2016 by the Global Polio Eradication Programme (GPEI) to monitor and guide the process of polio transition planning as the GPEI winds down its operations and eventually comes to a close in the post-eradication era. This fourth TIMB report is based on the presentations and discussions at the TIMB's November 3-5 2020 meeting. The Independent Monitoring Board (IMB) of the GPEI met shortly after this, and its 19th report ("The World is Waiting", available at Related Summaries, below) should be seen as a companion document to this TIMB report; the TIMB recommends that both reports be read to get a full understanding of the present moment.

In providing context, the TIMB notes that countries in a substantial part of the world, particularly in the regions reviewed below, have become reliant on the GPEI infrastructure to sustain broader public health functions beyond polio. Careful planning will be needed to protect these functions and ensure a smooth transition of responsibility and funding to the countries' governments as the GPEI winds down. The plan was for countries to "graduate" from GPEI funding starting in 2024. Due to the COVID-19 emergency, it is likely that other sources of financial support will have to be found for core capacities that have been polio-eradication funded for a long time. This could be necessary as soon as 2022.

The TIMB's three previous reports on polio transition planning (see Related Summaries, below) were carried out while the GPEI was facilitating and overseeing the polio transition planning process; now, the responsibility has shifted to the World Health Organization (WHO). That said, the TIMB stresses that the transition process cannot happen without cohesive partnership with the other spearheading polio-eradication partners (the United Nations Children's Fund (UNICEF), Gavi, Rotary International, the Bill & Melinda Gates Foundation, and the Centers for Disease Control and Prevention, or CDC), donor countries, wider polio collaborators, and other organisations and groups.

The countries' polio transition plans were written before the COVID-19 pandemic began. The pandemic has temporarily halted polio transition action, and, for most of 2020, the normal process of detailed assessment of the 20 polio transition countries' states of readiness and timetables has not been possible because of the constraints of COVID-19. However, country position statements were created, and the TIMB report shares them, by region:

• South-East Asia Region: There is a very strong commitment to polio transition planning in this region - e.g., from the WHO and in ministries of health and finance. The polio assets have been highly valued by the 5 polio transition countries in this region, which was certified polio-free in March 2014. Summaries of the country plans of Bangladesh, India, Indonesia, Myanmar, and Nepal are included.
• Eastern Mediterranean Region: The only region of the world yet to eradicate polio, there are 8 priority countries beset by both humanitarian crises and fragile governments that inevitably delay polio transition planning. The GPEI policy is that the polio-endemic countries of Pakistan and Afghanistan must focus on eradication and not embark on a transition programme; a full analysis of the polio situation in these 2 countries is in the 19th IMB report. Summaries of country plans for Iraq, Libya, Somalia, Sudan, Syria, and Yemen are included in the TIMB report.
• Africa Region: Certified free of wild poliovirus in August 2020, this region's 7 polio transition countries (Angola, Cameroon, Chad, Democratic Republic of the Congo (DRC), Ethiopia, Nigeria, and South Sudan) have been heavily impacted by COVID-19 and large vaccine-derived poliovirus (VDPV) outbreaks. Most of WHO's polio staff are in this region, so there is a heavy dependence by public health services on polio funding. There was hope that, beginning in 2020, money would be put into polio transition plans, but most of the countries are focused on tackling COVID-19 and maintaining existing government-funded essential services.

The report goes on to explore key considerations to achieving success for the essential immunisation component of polio transition planning. It also examines efforts to integrate polio into broader service delivery - efforts that are driven by the message that the the child should be seen as a whole person and not just a polio vaccine recipient or a measles vaccine recipient. Along those lines, Immunization Agenda 2030: A Global Strategy to Leave No One Behind has 7 strategic priorities that start with immunisation programmes for primary health care and universal health coverage and that are informed by 4 core principles: people-centred, country-owned, partnership-based, and data-guided. Polio is embedded in this Immunization Agenda 2030 vision and strategy, as well as in WHO's Thirteenth General Programme of Work 2019-2023, which includes targets related to securing universal health coverage, promoting health and well-being, and protecting people from health emergencies. This latter (health emergencies) function, through managing future polio events, is essential to creating a polio-free world, and is the last of the 3 pillars in the Strategic Action Plan on Polio Transition 2018-2023.

The need to secure and expand vaccine-preventable disease surveillance - the value of which has brought to the public's attention during the COVID-19 pandemic - became one of the key focus areas of the polio transition planning process early on; the report discusses the fact that polio resources have been subsidising activities in the field and in laboratories vital to preventing and controlling other diseases. The developmental work undertaken on surveillance, as part of the polio transition planning, entails: "broadening the range of diseases and markers of infection to be included, integrating the many ways that data are captured; developing standards and interoperability; and capitalising on digital methods of identification, analysis and communication."

A related consideration is biosecurity: the fact that, for example, just one mistake in handling or destroying samples of poliovirus could lead to the reintroduction of wild and/or vaccine-derived polioviruses in human populations. The goal of the containment part of polio transition planning is to achieve and sustain safe containment of polioviruses in facilities where the poliovirus is stored, worked upon, or may otherwise be present.

Following a section sharing data insights, the report offers analysis and discussion on progress toward the pillars of the Strategic Action Plan on Polio Transition 2018-2023. The TIMB asserts that the requirement to assess progress towards countries' financial self-sufficiency and responsibility for polio-eradication-funded health functions is an essential element of the independent monitoring process and is particularly important in light of the damage caused to domestic enconomies by COVID-19. "[T]he continuation of all the traditional GPEI functions, consequent on the failure to remove the final two countries from the polio-endemic list, is causing uncertainty about respective responsibilities and the timing of their transfer. Very few polio transition priority countries are yet in a position to take over their polio assets and staff. But WHO's creation of a core budget for this purpose will help to bridge the gap. Key policy decisions are now needed about which aspects of polio transition should be fully implemented and on what timescale."

Recommendations include:

1. Decide whether the GPEI should continue to manage and coordinate all polio functions or whether a subset of functions should move permanently to other global management structures to advance polio transition.
2. Reassess each of the 20 polio priority transition countries' plans in light of COVID-19.
3. Expand the model of integrated public health teams (polio, essential immunisation, surveillance, health emergencies) at the country level.
4. Formulate and implement a comprehensive human capacity-building plan.
5. Further develop a global comprehensive communicable disease surveillance system.
6. Establish a containment programme within the polio transition planning process.
7. Strengthen global oversight, coordination, and performance management for essential immunisation.
8. Involve the polio transition team in the implementation of IMB recommendations.
9. Conduct subnational mappings of capacity and capability to contribute to the objectives of polio transition in the priority countries.
10. Publish a comprehensive risk register covering all aspects of polio transition planning.