The results of 2 large field studies on the impact of the polio eradication initiative on health systems and 3 supplementary reports were presented at a December 1999 meeting convened by the World Health Organization.
All of these studies concluded that positive synergies exist between polio eradication and health systems but that these synergies have not been vigorously exploited. The eradication of polio has probably improved health systems worldwide by broadening distribution of vitamin A supplements, improving cooperation among enterovirus laboratories, and facilitating linkages between health workers and their communities. The results of these studies also show that eliminating polio did not cause a diminution of funding for immunization against other illnesses. Relatively little is known about the opportunity costs of polio eradication.
Improved planning in disease eradication initiatives can minimize disruptions in the delivery of other services. Future initiatives should include indicators and baseline data for monitoring effects on health systems development.
THERE HAS BEEN CONSIDERable controversy about the effects of the polio eradication initiative on health systems development. Some observers believe that polio eradication has detracted from health service delivery and has been detrimental to a sound, integrated approach to health systems development.1 Defenders of polio eradication have argued that any untoward effects of the initiative have been relatively minor and are outweighed by the benefits.2,3
Before 1999, the only large, multicountry study to examine the impact of polio eradication on health systems was conducted by the Taylor Commission, convened by the Pan American Health Organization in 1995.4 Using interview data from communities, governments, nongovernmental organizations, and health staff in 6 countries, the commission concluded that polio eradication had “contributed positively to overall strengthening of health systems in the Americas.” Positive responses outnumbered negative responses by a 4 to 1 margin, and probing was required to elicit negative comments. The greatest positive impacts were in the areas of social mobilization and intersectoral cooperation. The report stressed the importance of implementing polio eradication as part of “systematic programs to build health infrastructure” and warned against generalizing the findings to “less developed” regions of the world.
This article outlines 2 large new studies that have systematically examined the impact of polio eradication on health systems and health service delivery in Asia and Africa and 3 new supplementary reports that have reviewed specific aspects of polio eradication (Table 1). These studies and reports were presented at a December 1999 meeting (“The Impact of Targeted Programmes on Health Systems: A Case Study of the Polio Eradication Initiative”) convened by the World Health Organization (WHO).5 We summarize the discussions of these papers and complementary data.
The 2 large studies were carefully designed and primarily qualitative, examining the effects of polio eradication on health systems development in broad terms.6,7 The All India Institute of Medical Sciences (AIIMS) and the India Clinical Epidemiology Network (IndiaCLEN), with financial support from the United States Agency for International Development (USAID), studied the gains of the polio eradication program and its impact on other health services. The study was also designed to identify lessons for improving implementation of polio eradication and mechanisms for extending gains to other primary health care activities. In-depth interviews and focus group discussions were conducted with 2159 stakeholders, ranging from mothers to the prime minister of India, over a 2-year period. The study took place in 24 districts of diverse socioeconomic status in 15 of the 30 Indian states.6
The second large study was commissioned by WHO with multidonor funding. An independent team of consultants interviewed key health ministry staff informants from the district to national levels and reviewed financial, planning, and surveillance documents to examine the effects of polio eradication on policy context, resource inputs, organizational capacity, service delivery, collaboration and partnerships, and social mobilization.7 The study was carried out in Tanzania, Nepal, and the Lao People's Democratic Republic over a 2-year period.
The supplementary reports examined 3 specific aspects of polio eradication. The USAIDsupported Partnership for Health Reform project evaluated 1997– 1999 immunization finance data from Côte d'Ivoire, Bangladesh, and Morocco to investigate the impact of polio eradication on the funding of other immunization services.8 The Quality Assurance Project, with support from USAID, conducted a review of the Global Polio Laboratory Network to determine whether key quality principles used in the network could be cited as a “best practices model” for other health programs (e.g., those focusing on malaria or tuberculosis) that rely on laboratory results to guide decision making.9 Data were presented from WHO and the United Nations Children's Fund (UNICEF) on the number of countries that include distribution of vitamin A supplements during national polio immunization days.10
The principal findings of the studies, reports, and discussions can be summarized into 2 broad categories, polio eradication's impact on health systems and its impact on health service delivery.5 In the area of health systems, the findings and discussions focused on health services management, intersectoral collaboration, political and societal mobilization, and human and financial resource allocation. Evaluations of health service delivery concentrated on the effect of polio eradication on routine immunization services and disease surveillance networks.
The AIIMS study concluded that the health system effects of polio eradication had mostly been positive but that there were “threats” that had to be recognized explicitly and dealt with preemptively. Polio eradication had strengthened management capacity, improved social mobilization, and increased confidence in the health care system. However, better planning was required to minimize the health service delivery disruptions caused by national polio immunization days.
The WHO-commissioned study concluded that polio eradication had not had a very significant impact, either positive or negative, on health systems. The authors indicated that most of the negative effects they had found could have been averted through better planning and that positive effects could be achieved only by having clear objectives and explicitly working toward them. References were made to “missed opportunities” for promoting routine immunization and other preventive services and including such activities in polio eradication training sessions and materials.
Both studies concluded that there had been some positive effects of polio eradication on health systems management. For example, in Nepal the national immunization days represented the first occasion that funds were released directly to regions and districts. In the Lao People's Democratic Republic, polio eradication helped promote a new district strategy that stressed health care delivery closer to the community. These evaluations also recognized that much more could have been done to institutionalize the good management practices engendered by polio eradication.
The AIIMS and WHOcommissioned studies concurred that polio eradication established effective intersectoral collaboration. For example, in a number of countries it was found that collaboration mechanisms established for polio eradication provided models that were used during other disease epidemics. However, it was noted that interagency coordinating committees that had been established to assist in polio eradication were not always used to strengthen the immunization program as a whole.
There was consensus from the AIIMS and WHO-commissioned studies that polio eradication helped improve communities' perceptions of health services, including the political support given to health care systems. For example, in India the national immunization days improved the confidence of mothers in health workers and helped change their perception that health workers were interested only in family planning. Both evaluations revealed that social mobilization efforts had been widespread and successful.
The Partnership for Health Reform study on immunization financing concluded that (1) funding for routine immunization had increased since PE initiation, (2) government funding of routine immunization had increased since initiation of polio eradication, and (3) in Côte D'Ivoire and Morocco, but not Bangladesh, the government had increased its annual expenditure on polio eradication.8 These results suggest that there was little financial trade-off between polio eradication and routine immunization, although the impact of polio eradication on the financing of other aspects of health budgets was beyond the scope of the study.
The authors of the WHOcommissioned study found no evidence that polio eradication had reduced the financial resources available for other health services in the Lao People's Democratic Republic, Nepal, or Tanzania. Supplementary information presented by WHO during the meeting demonstrated that of the estimated $319 million in external donor funding for polio eradication activities in 1999, more than 80% had not been previously targeted for developing country immunization services (J. Linkins, WHO, written communication, December 17, 1999). As much as 50% of the external polio eradication financing in that year was derived from funding sources such as Rotary International that had not previously contributed to official development assistance for health.11
Some observers have expressed concern that there are significant opportunity costs associated with polio eradication when health staff are taken away from other important activities to focus on national immunization days. The WHO-commissioned study addressed this issue explicitly, assessing the amount of time health workers devoted to polio eradication in the Lao People's Democratic Republic, Nepal, and Tanzania. The authors calculated that the demands of polio eradication on work time increased toward the peripheral level of the health system, where staff spent as many as 12 days per year on this activity (about 5% of their working time). The effect on the delivery of other health services, however, depended very much on staff productivity. In the countries examined in the study, polio eradication activities were not believed to have compromised other activities because of the substantial “slack” that was present in the system.
The AIIMS and WHOcommissioned studies did conclude that disruptions in the delivery of other health services had occurred and in some cases may have been serious. For example, the authors of the WHO study described a report from Nepal indicating that family planning activities were “somewhat” hampered by the national immunization days because they coincided with the most suitable times for sterilization camps. However, the authors also found that routinely reported monthly data on maternal and child health services had not changed relative to the pre– polio eradication period. According to the AIIMS study, half of all stakeholders interviewed believed polio eradication had actually improved primary health care services, although concern was expressed that villagers might come to expect other health services to be delivered in a similar house-to-house manner. Both studies concluded that the negative effects of polio eradication could have been prevented with better planning.
All of the studies included qualitative findings and anecdotes, both positive and negative, regarding the effect of polio eradication on at least some aspects of routine immunization services. The WHO-commissioned study and a UNICEF rapid appraisal in Niger and Benin (J. Zucker, UNICEF, written communication, December 17, 1999) attempted to examine this issue quantitatively, but the analyses were hampered by a lack of baseline coverage survey data and coincidental health reforms such as decentralization.
Data from the WHO-commissioned study demonstrated that the relationship between polio eradication and routine immunization coverage was difficult to assess. Both the Lao People's Democratic Republic and Nepal experienced increases in routine coverage after initiation of national immunization days, but these increases coincided with an expansion in the number of peripheral health facilities. In Tanzania, health sector reforms, including decentralization, “overshadowed any possible impact” of polio eradication on routine services. The UNICEF rapid appraisal revealed that there was no relationship between polio eradication activities and routine immunization coverage in Benin and that the poor performance of routine services in Niger did not improve. The appraisal did identify “missed opportunities” to coordinate planning activities, training sessions, and cold chain vaccine management between polio eradication and routine immunization services.
A specific aspect of health service delivery about which there was broad consensus was the promotion of vitamin A supplementation in appropriate countries. One analysis showed that 40 countries had used national immunization days to deliver vitamin A to more than 60 million children.10 Because these countries represented 34% of the 118 countries where vitamin A deficiency is a public health problem, and given the impact of supplementation (a 23% reduction in overall mortality among children aged 6 to 59 months12), this constituted a significant contribution of polio eradication to child survival.13
Eradication programs make substantial human and financial investments in strengthening of disease surveillance, including diagnostic laboratory capacity. The AIIMS and WHO-commissioned studies investigated whether such investments in polio eradication had wider benefits. Both evaluations showed that acute flaccid paralysis surveillance for PE had been successfully implemented in most countries. Whereas polio-generated surveillance improvements have enhanced surveillance for other diseases in the Americas, however, there was not yet evidence of a similar impact in other parts of the world. The potential for a wider positive effect in this regard was evident in the considerable cooperation reported by the Quality Assurance Project within the network of 150 polio laboratories worldwide.9 This unique cooperation, which includes strict quality control, accreditation, and regular supervision, has led to substantial improvements in the performance of these laboratories.
Quantitative studies on the effects of polio eradication on health systems development have been hampered by the lack of credible baseline data, the absence of control groups (areas that have not implemented polio eradication strategies), and the concurrent implementation of major health system reforms such as decentralization. Consequently, the available data are mostly qualitative and country specific, and the conclusions are not readily generalizable.
Researchers agree that positive synergies exist between polio eradication and health systems development but that these synergies have not been vigorously exploited. Similar to the Taylor Commission report, the AIIMS study was upbeat about the net benefits of polio eradication, while the WHO-commissioned study revealed little effect, either positive or negative, on health systems. Both studies agreed with the Taylor Commission that there were positive effects of polio eradication on health systems management, relations with the community, social mobilization, and intersectoral collaboration.
Two clear benefits of polio eradication have been the distribution of vitamin A supplements to large numbers of children and improved cooperation and capacity among enterovirus laboratories worldwide. It is encouraging that despite its higher than anticipated financial cost, polio eradication does not appear to have drawn substantial funding away from other aspects of immunization. In the countries studied in detail, governments and partners are spending more on routine immunization since initiation of polio eradication programs.8
There remain, however, large gaps in our knowledge of the impact of polio eradication, particularly regarding important aspects of routine immunization such as service delivery and evaluation and monitoring. In regard to major health system components, the impact of polio eradication has been systematically studied only in terms of management and delivery of health services and, to a lesser extent, mobilization and allocation of financial and human resources.14,15 Much less is known about the impact of polio eradication on policy, regulatory, and strategic planning functions and the definition and development of institutional arrangements.
Further study is needed on the opportunity costs of polio eradication for the delivery of other services, including the availability of emergency curative services. It is unclear what long-term impact the successful polio eradication public–private partnership will have on health policy setting and funding. In an even broader context, the effects of polio eradication on areas such as peace building and global-level disease control alliances have yet to be documented in detail.16
The report of the WHOconvened meeting included several recommendations for optimizing the opportunities provided by targeted programs to strengthen health systems while minimizing the threats to their development.5 First, greater synergies between polio eradication and the strengthening of health systems should be achieved through renewed focus on routine immunization, expanding acute flaccid paralysis surveillance to include other diseases, ensuring vitamin A supplementation during routine immunization contacts, and including other health services in polio eradication training and supervision.
Second, planning should be improved to avoid disruptions and increase the likelihood of positive spin-offs. Third, additional work should be conducted to evaluate the previously noted gaps in understanding of the effects of polio eradication. Fourth, stronger linkages should be forged with the institutions addressing strengthening of health systems. Finally, future eradication programs should explicitly address at the outset how they will help strengthen health systems and should have specific goals, indicators, and baseline data against which to measure progress.
The overall findings of this important meeting on polio eradication and health systems were perhaps best expressed by the authors of the WHO-commissioned study. According to these researchers, positive impacts are not automatic; they have to be deliberately planned.7
Note. WHO = World Health Organization. IndiaCLEN = India Clinical Epidemiology Network. aPapers presented at the December 1999 meeting The Impact of Targeted Programs on Health Systems: A Case Study of the Polio Eradication Initiative.5
Title of Study (Year) Institutional Affiliation (Location) Study Sites Methods Study Objective Disease Eradication: Friend or Foe to Health System (1999) Centre for Partnership in Development (Oslo, Norway) and Karolinska Institute (Stockholm, Sweden) Tanzania, Lao PDR, Nepal Systematic interviews, statistical and document review using health systems capacity assessment framework of indicators. Evaluate the impact of PE on health systems Pulse Polio Immunization Program Evaluation (1997–98, 1998–99) All India Institute of Medical Research, IndiaCLEN (Delhi, India) India Interviews and focus group discussions with key informants and stakeholders at all levels. Evaluate the impact of PE on the delivery of other health services The Impact of the Polio Eradication Campaign on Financing of Routine EPI: Findings of Three Case Studies (1999) Partnership for Health Reform, University Research Co. (Bethesda, Md) Bangladesh, Morocco, Côte d'Ivoire Trend analysis of source and use of funds, survey. Determine effect of PE on developing country immunization financing trends Global Polio Laboratory Network: A Model for Good Laboratory Practice (1999) Quality Assurance Project, University Research Co. (Bethesda, Md) United States, India, South Africa, Uganda Observation of lab practices and interviews with laboratory staff. Determine lessons learned from the Global Polio Laboratory Network Polio as a Platform: Using National Immunization Days to Delivery Vitamin A Supplements (1999) WHO (Geneva, Switzerland) and UNICEF (New York, NY) 40 countries Review of data reported to the WHO Vaccine Preventable Diseases Monitoring System Evaluate PE as an entry point for sustainable provision of vitamin A
Note. WHO = World Health Organization. IndiaCLEN = India Clinical Epidemiology Network.
aPapers presented at the December 1999 meeting The Impact of Targeted Programs on Health Systems: A Case Study of the Polio Eradication Initiative.5