Community engagement: The polio programme integrated communications and community engagement within its overall operations, enabling it to achieve the highest polio vaccination acceptance rates in the world.
Localizing communication messages and their outreach, presenting vaccinators as intertwined members of communities helped directly build trust, and emphasizing local ownership of the programme helped allay misconceptions and allowed community ownership.
Female community-based vaccinators played a pivotal role in turning the table around in favour of polio drops. The programme introduced local female community-based vaccinators as advocates of the polio vaccine. These women, as the most trusted figures of the communities, brought a positive change in the attitudes and behaviours of caregivers and helped them take an informed decision to vaccinate their children against the crippling disease.
Vaccine hesitancy and vaccine refusals were substantially reduced to small pockets of caregivers through innovative programme interventions. To further eliminate the 0.12 percent refusals at the time, while the program continued to maintain broad support nationally – which was imperative as the perception of the risk of infection came down with the fewer polio cases; from 306 in 2014 to 8 in 2017 – community engagement was embedded at the operational level at the province and district level targeting pockets of those refusing families.
Over 2,000 social mobilisers and religious support persons were assisted by key influencers; teachers, religious scholars; paediatricians; revenue staff; district administration who worked locally to address misconceptions and fake news, to build trust around the vaccine and increase demand and vaccine acceptance. It was evident pretty early that one size does not fit all. Thus, these localised and focused communication and community engagement approaches addressed operational issues as well as communication gaps of repeated vaccination, misconceptions/rumours and vaccine efficacy and safety highlighted by the Knowledge, Attitudes and Practices Study undertaken in 2017 and through continuous system of field feedback.
While vaccine hesitancy is not a new phenomenon and one that the polio programme continues to battle till today, the challenges for creating demand for the Covid vaccine(s) that is being used for the first time globally were bound to be more serious. Coupled with fears of fast-tracking vaccines for commercial use and possibly compromising safety aspects in clinical trials to future implications and likely side effects further compounds the communication challenge.
These unique challenges required preparing the ground in advance using scientific data by hard-core disease control experts. Instead, we saw confusing and contradictory messages from the top political leadership of the country that led to a diffused narrative on the significance and urgency of Covid-19 vaccination. Pakistan needed a clear, crisp and consistent communication strategy from day one. The government is well advised to immediately address Covid vaccine hesitancy evident in the abysmally low vaccine uptake and poor vaccine registration by employing localised communication strategies and aggressively pursuing advocacy and social mobilisation through the use of trusted and respected local and national influencers to build trust and improve acceptance.
Data-driven management: Instead of uninformed decision-making that is motivated by political expediencies or a result of knee-jerk reactions, policy decisions in the polio programme were based on scientific evidence, ensuring that programme operations were driven by the best available data and operational research, with information reaching decision-makers and frontline staff in a timely manner and in a format that helped drive programme priorities, performance and accountability. This is key for any programme, as vital as it was in driving the polio program then as it is today for an informed response to the Covid pandemic. The range of data and research that was used for disease modelling, the knowledge attitudes practice surveys, seroprevalence studies to operational and campaign monitoring of the polio programme ensured that it was closing any gaps as it moved towards the finish line.
Data from the fairly short life span of the Covid virus should be thrashed, patterns of spread and virus epidemiology examined constantly for more informed decision-making. Instead of using rhetoric and populist decisions for political point scoring, epidemiologist and infectious disease experts should be consulted and taken on board. The knowledge set from the polio programme regarding high risk population groups, social dynamics and understanding of health seeking behaviour should be utilised effectively to plan and constantly evaluate service delivery and communications.
The country has won international acclaim once by the World Economic Forum when it utilised polio assets for Covid surveillance and response during the first wave of. “Community health workers who have been trained to go door-to-door vaccinating children against polio have been redeployed and utilised for surveillance, contact tracing and care,” recognised Dr Tedros Ghebreyesus. However, mere collection of quality data through the polio programme is a futile exercise unless it is effectively utilised for evidence based, scientific and timely decision-making.
Reaching vulnerable and hardest to reach populations for equitable vaccination: Pakistan is the fifth most populous country in the world with 40 million children under the age of five and over seven million children born each year. Because of a difficult terrain and uneven availability of health services including health workers and cold chain logistics, reaching people equitably with vaccines remote areas is challenging. Moreover, low population immunization rates and rampant malnutrition further exacerbate the immunity risk especially amongst women and children in these areas. The disparity in health equity is far more pronounced across provinces and districts.
These dynamics and disparities should have been kept in mind before devising a Covid vaccination plan/strategy that would have ensured equitable vaccination across the urban and rural divide, and across all provinces and districts of Pakistan. Data from across the over 1000 plus Covid vaccination centres around the country should be reviewed constantly to assess weak areas/districts to design special interventions for improving vaccine uptake. This information should be complemented with data from the polio programme on critical populations in helping to identify and reach most vulnerable groups.
Maintaining vigilance through active surveillance: Pakistan developed the largest polio surveillance network in the world which helped the polio programme track the virus, detect it early and respond to it effectively. This played a critical role in providing insight into the transmission dynamics of the poliovirus in Pakistan. Bad news in the present was good news for the programme as it allowed us to respond rapidly before transmission to other families/ districts/ provinces.
Similarly, testing for Covid-19 needs to be enhanced substantially, and not just in our metropolitan cities but also rural villages and smaller towns, to enable timely detection and effective response. Currently, there are only 41 districts that have laboratories, public and private, equipped for Covid testing, this number needs to be expanded and the cost of test subsidised.
The cost of failure is too high to ignore these lessons from Pakistan’s polio programme. With 1,762,319 precious lives lost to Covid-19 across the globe and 19,617 in Pakistan to date, any callousness in wrong/mixed messaging or half-hearted attempts at creating demand and acceptance for the Covid vaccination will be tantamount to criminal negligence and can continue to have devastating effects.
As the PM’s focal person on polio eradication, while I participated in Rotary’s celebrations in Delhi in 2016 to mark India’s polio-free status, I made a silent note to myself to emulate India in the fight against polio. Today, I am again taking note and hoping that now India’s missteps are not repeated and that this pandemic does not turn into a humanitarian crisis of the level being seen in our immediate neighbourhood. For this, we need to be extremely vigilant in tracing the virus to protect and prevent ourselves from death and disease. We need to make informed decisions based on real-time data and not our political whims, and pursue a consistent and clear communication and community engagement strategy.
A safer exit from the pandemic is in everybody’s interest. Without wasting further time, the government must do everything possible to bring all stakeholders together and across the political divide to bind the nation together so as to return life to normalcy sooner than later.