Lessons Learned from the Global Polio Eradication Initiative Published in Special Supplement

The Global Polio Eradication Initiative (GPEI) is a 30-year effort to eradicate polio and its associated severe diseases. Researchers from the Johns Hopkins Bloomberg School of Public Health, in collaboration with seven academic and research country partners, set out to capture the lessons learned from the GPEI in a project called Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE). The journal supplement, Lessons Learned from Global Polio Eradication – Part 1, is the first collection of articles describing lessons from the polio eradication experience to date under the STRIPE project.

Lessons Learned from Global Polio Eradication – Part 1 was published in BMC Public Health on August 12, 2020.

“If we don’t learn from our experiences in combating polio—the largest public health emergency in human history—we are bound to repeat the same mistakes in facing novel infectious diseases such as COVID-19 and other public health emergencies in the future,” says Olakunle Alonge, MD, PhD ’13, MPH ’09, an assistant professor in the Department of International Health and STRIPE project lead.

The global effort to eliminate the spread of poliovirus and sustain the polio-free status of countries is affected by a number of factors and challenges—such as politics, demand and supply issues, societal issues, and conflicts and insecurity—that is not unique to polio but also affects efforts to eliminate other diseases, including malaria, Ebola and COVID-19. GPEI is one of the largest public health efforts of its kind, involving collaboration among stakeholders across different types of organizations and cooperation among government at global, national, and local levels, with the result of distributing hundreds of billions of doses of polio vaccines. The STRIPE project aims to serve as a guide for improving the efficiency and effectiveness of other eradication and global control programs, as well as efforts to address global public health emergencies, such as COVID-19.

In this supplement the STRIPE project identified barriers to implementing the GPEI at multiple levels—global, national, and subnational—and strategies for addressing them so that they may be useful for the effective implementation of other global health programs.

The authors found that major implementation barriers to the GPEI were external, including social, economic, and political factors. A common social barrier was low vaccine demand, due to low levels of awareness of the benefits of immunization, vaccine hesitancy, and fatigue with vaccination programs in countries where households received frequent vaccination campaigns. Economic factors included low economic development and chronic underfunding of health systems where polio eradication programs were occurring. Many basic and essential services—such as water and sanitation—were not being provided, leading to suspicions of the promotion of the polio program while basic livelihood necessities were neglected. Political factors, such as a lack of political will and insecurity and conflict led to difficulty in sustaining program support through election cycles and disruptions to service delivery.

In addition to external barriers, internal barriers related to the process of implementing polio eradication activities were also common. Program execution, engagement, evaluation and planning, and health systems-related gaps such as human resources and supply chain issues were frequent challenges.

Key lessons learned from the GPEI for future global health programs include:

• Identify issues related to external factors early on and actively strategize around them on a continuous basis throughout the entire life of the program. The lack of understanding around broader political, social, and economic contexts surrounding communities has been and continues to be a major barrier to achieving polio eradication goals.
• Conduct a careful and thorough pre-program analysis of the broader political, social, and economic contexts to identify both threats and opportunities to successful program implementation. This will allow the program to avoid addressing implementation barriers in a reactionary manner and will save time and lower costs.
• Implement a core set of principles: ongoing stakeholder engagement based upon mutual respect, coordinating efforts to build political will and accountability over different phases of the program and at different sociological levels, systematic adaptation of service delivery activities to local contexts, and establishing sound planning, management, and monitoring and evaluation practices which measure implementation outcomes in addition to endpoint outcomes.
• In order to minimize negative unintended outcomes, policymakers need to give adequate attention to participatory approaches which can facilitate implementation processes across socioecological levels, especially at national and subnational levels.
• Efforts to implement global health programs should be accompanied with efforts to build social capital.

Few of the prior studies on documenting lessons learned from the GPEI have focused on knowledge learned from a multilevel (global, national, and subnational) perspective. To ensure widespread uptake of key public health lessons from such an endeavor as the GPEI, disseminating and incorporating the lessons learned from the initiative is essential for future lifesaving initiatives.

STRIPE includes partners from focus countries representing different epidemiological classifications for polio—endemic, outbreak, at-risk and polio-free. These include Afghanistan, Bangladesh, the DRC, Ethiopia, India, Indonesia, and Nigeria. Research partners from these countries include Global Innovations Consultancy Services (Afghanistan), the James P Grant School of Public Health, BRAC University (Bangladesh), the University of Kinshasa School of Public Health (Democratic Republic of Congo), the School of Public Health, Addis Ababa University (Ethiopia), the Institute of Health Management Research (India), the Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada (Indonesia), and the College of Medicine, University of Ibadan (Nigeria).

Johns Hopkins University authors of the articles in the supplement include

• Olakunle Alonge, Assistant Professor, Department of International Health, Johns Hopkins Bloomberg School of Public Health
• Ellie Decker, Senior Research Program Coordinator, Johns Hopkins School of Nursing
• Anna Kalbarczyk, Assistant Scientist, Department of International Health, Johns Hopkins Bloomberg School of Public Health
• Abigail Neel, Research Associate, Department of International Health, Johns Hopkins Bloomberg School of Public Health
  Michael Peters, PhD Candidate, Department of International Health, Johns Hopkins Bloomberg School of Public Health
• Aditi Rao, Associate, Department of International Health, Johns Hopkins Bloomberg School of Public Health

The supplement includes the following articles:

• What can over 30 years of efforts to eradicate polio teach us about global health
• Synthesis and translation of research and innovations from polio eradication (STRIPE): initial findings from a global mixed methods study
• Sampling method for surveying complex and multi-institutional partnerships: lessons from the Global Polio Eradication Initiative
• Evaluating the process of partnership and research in global health: reflections from the STRIPE project

Synthesis and Translation of Research and Innovations from Polio Eradication is funded by the Bill & Melinda Gates Foundation.