Major internal contributor to service delivery
Strengthening service delivery on the supply side of the health system involves improving quality and availability of services provided at point-of-care in health facilities, and focuses on training, skill building and task shifting. On the demand side, it involves removing barriers to access to health services such as bringing health services to the most vulnerable populations. Our study showed that the process of implementing activities was the most important internal contributor to strengthening service delivery. Furthermore, strategiesaimed at systematically increasing access to healthcare services were identified as pivotal to strengthening service delivery in hard-to-reach, remote, and vulnerable populations.Some of these strategies included the use of innovative technology like geographic information systems to identify chronically unvaccinated children,(15) inclusion of nomadic communities to develop immunization plans,(15) transit vaccinations at major transportation hubs and markets,(27)and using military personnel as vaccinators during supplementary immunization activities in regions of violent conflicts.(28) These strategies subsequently improved not only polio immunization coverage, but also had spillover effects that improved service delivery and contributed to increased routine immunization coverage in regions where they were implemented.(15)
Our study found that there were significantly higher odds of identifying the polio implementation process as the main internal contributor of strengtheningservice delivery in South-East Asia compared to other regions. In India, the training of frontline and community health workers who implemented the social mobilization network (SMNet) program was not limited to polio immunization activities. They were also trained to promote general maternal and child health including tracking children’s complete vaccination history, home management of childhood diarrhea, household hygiene, and breastfeeding promotion. (17,29)Such programs that extended beyond polio immunization to address broader public health priorities contributed to strengthening service delivery. Some studies showed that SMNetprogram continued to support routine childhood immunization, and improved primary health care service delivery in Uttar Pradesh, Bihar and West Bengal. (14,17,29)In Indonesia, the polio program was integrated in the existing sub-national government institutions for immunization.(30)At the community level, integrated health services posts (“Posyandu”) delivered polio immunization along with maternal and child health and nutrition, which may have contributed to stronger health service delivery.(30)We found lower odds of identifying polio implementation process as a main internal contributor for strengthening service delivery in Eastern Mediterranean region. For example, in Pakistan, polio supplementary immunization activites were criticized as being disjointed from routine childhood immunization services and other primary health care services.(31) Similarly in Afghanistan, Rodriguez et al found that the extensive separation of polio program from routine immunization significantly impacted service delivery strengthening at the sub-national levels.(8)
There is documented evidence on the impact of PEI in improving RI, and the integrationof Vitamin A supplementation and RI with polio activities.(11). In addition, the GPEI’s infrastructural assets, investments and impactcould be applicable to other aspects of population health. The 19th polio Independent Monitoring Board (IMB) report showed that countries in Africa and East Mediterranean used their existing polio eradication infrastructure ranging from human resources to data management, communication and surveillanceworth over 100M USD, as part of their COVID-19 pandemic response.(32)Similarly, during the 2014-2016 West Africa Ebola outbreak, Nigeria deployed existing polio assets for prompt detection and quickly quelled the spread.(33,34)
Beyondthe intermittent emergency response applications, polio presents a unique opportunity to re-design servicedelivery using an integrated, people-centered approach. Importantly, this approach takes advantage of the existing knowledge and investments from the PEI. For example,similar GIS techniques used for micro-planning during polio eradication activities (35,36)can also be utilized for planningnon-communicable disease screening and targeted maternal health interventions. Additional interventions can also be integrated into polio activities. For example, when parents and caregivers bring children for vaccination during supplementary immunization days, or during door-to-door campaigns, blood pressure readings and finger prick tests to screen for hypertension and diabetes, respectively, could be integrated into these visits. Countries can leverage GPEI infrastructural assets and knowledge to bring these services to the doorsteps of vulnerable populations for prioritized interventions.
Main external contributor and implementation challenge
We found the most important external contributor to strengthen service delivery was the social environment, especially among those whose roles interfaced directly with communities and beneficiaries. The elements of the social environment included developing high levels of trust in health workers,transparency in the vaccination process and building community awareness. Conversely, the external environment was identified as the main implementation challenge hampering the strengthening of service delivery. We found respondents in Eastern Mediterranean region had significantly higher odds of identifying the external environment as the most important implementation challenge compared to the reference region. In the two remaining polio-endemic countries, the complex external environment challenges were similarly characterized. Respondents cited security challenges, and community resistance to polio eradication interventions as the main forms of implementation challenges experienced. A recent review found insecurity and conflicts remain a persistent barrier to service delivery in Pakistan, (31)and Afghanistan continues to grapple with complex challenges of prolonged religious and ethnic conflicts, mistrust in health workers and political upheavals. (37)Community resistance is often the manifestation of a lack of community trust, which was a major challenge in the eradication of polio according to the polioIMB.(32) In high-conflict and high-risk states like Pakistan, lack of trust in polio vaccinators was also identified as a major challenge impeding polio eradication.(38)
Strategies to mitigate community resistance while circumventing security challenges included shorter immunization days (‘hit-and-run’)and using elderly traditional birth attendants as part of permanent community health teams in high-conflict areas in Nigeria.(39)In Ethiopia, the use of community volunteers (CVs) to secure community trust by addressingmisconceptions about polio vaccines while helping implementers identify routes to hard-to-reach, border communitieswas effective. (40)In India, the social mobilization networks created communication channels to reach high-burden communitiesthat were typically impoverished, laden with other non-polio priorities, hadcultural/religious conservatism, and generally distrustful of government. (41)
Building trust between health workers and communities requires a medium to long-term approach before achieving success.(40) It entails contextualizing social mobilization and community awareness activitiesin individual communities to improve buy-in and participation. Unlike smallpox, or COVID-19 that involved one or two vaccination shots, polio eradication requires multiple contacts with the health system before vaccination, similar toother publichealth services like RI, hypertension or diabetes management, cancer screening, antenatal care, and other services that make up the essential health services package of universal health coverage in many countries. Thus, when communities need multiple, repeated contacts with the health system, building trust requires constant communication with consistent messaging, while modeling health promoting behaviors, and understanding cultural norms. Health care providers and community health workers who are often the first contacts in the health system need to transform beyond providing health services (competence and knowledge) to become trust agents (morality and compassion for the people they serve)fostering community ownership and engagement while serving aspillars to strengthen service delivery.(41)This is fundamental to one of the primary health care principles to ensure communities can afford to sustain health at all levels of their development.(42)
Implications for Universal Health Coverage
Reviewing the health system’s capacity to deliver on UHC priorities should include information on service delivery(43) because making progress towards national UHC goals is contingent on strengthening service delivery.(3)Vertical programs like GPEI can both contribute and hamper UHC efforts at global, national, and subnational levels. At subnational levels, they hamper UHC efforts when programsarenot aligned with the community’s priorities and contribute to UHC when the programsare a direct response to the community’s needs and priorities. In some communities, these vertical programs are the healthcare lifeline when health budgets are insufficient. The assets from polio eradication programsincluding resources and dedicated manpower at the subnational levels can be leveraged to support broader systemic UHC efforts like improving availability and quality of service delivery which has direct impact on the population.
The need for a comprehensive primary health care delivery model that promotes interaction by health care professionals and the community in the formulation and execution of health goals at personal and community level have been previously documented.(44) This model which is based on community identified needs is framed on program flexibility, adaptation, interdisciplinary partnership, on-going evaluation, and adjustment of services to meet emerging needs.(44) The integration of GPEI with other primary care services have been shown to expand coverage for maternal, newborn and child health services in hard-to-reach communities which are unlikely to have contact with basic health care. (18) In Nigeria, this model led to increased awareness on other vaccine preventable diseases (such as measles, cerebrospinal meningitis, yellow fever, pertussis) and increased access to health services at the nearest health facility.(18)Similarly, following an integrated campaign for insecticide treated nets (ITN) and polio vaccination in Niger, there was substantial increase in ITN ownership with accompanied decrease in inequities between highest and lowest wealth quintiles.(45)
Currently, there is a focus on integration of implementation of PEI and RI as evidenced by the recent strategic plans of Gavi Phase V (2021-2025),(46) the upcoming Polio Eradication Strategy (2022-2026),(47) and the launch of the interim Program of Work for Integrated Actions that synergizes GPEI and the Essential Programme on Immunization (EPI) in the context of COVID-19. (48)Integration needs to extend beyond vertical programs to diagonal, multi-dimensional, equity-focused integration that incorporates primary health care, effective preventive interventions, and clinical management to strengthen service delivery in the health systems. (49)Afghanistan and Pakistan, the remaining two polio-endemic countries are exemplary as they have documented plans to integrate PEI with other basic primary health care services as a UHC package of essential services. (32)
In developing and implementing national UHC plans, the external environment should not be overlooked. We found that the external environment was the most significant challenge to strengthening service delivery. This included factors beyond the scope of the health sector alone such as perennial violent conflicts, political upheavals, monumental changes e.g., moving from centralized to decentralized system of governance; all of which would have varying impacts on the demand and supply sides of the health system. Multisectoral expertise beyond the health sector (education, family affairs, youth empowerment, military etc.) should be drawn upon to address the external environment challenges that would otherwise impede implementation and progress towards achieving UHC. In the context of UHC, service delivery needs to be re-imagined for implementing integrated, essentialprimary healthcare services that requires regular touchpoints and community ownership. To achieve UHC, this integration needs to be expanded beyond pandemic and emergency responses to incorporate basic essential services, leverage synergies provided by various donor-funded vertical programs to maximize capabilities, fill gaps, and transform the biggest implementation challenges into pillars for strengthening service delivery.
Strengths & limitations
Our study focused on the national and subnational levels of implementation where service delivery happens. Thus, we captured program implementation knowledge that are closest to the communities. There were some limitations in our study.We did not capture the experiences of polio beneficiaries across levels. Also, the online survey format might have missed some of the ground-level workers in more remote communities. However, our findings were robust to capture experiences across different countries and contexts, and we cross-pollinated responses to identify the most common and largest contributors and challenges in the various polio eradication implementation contexts.