The Global Polio Eradication Initiative: Progress, Lessons Learned, And Polio Legacy Transition Planning

"Transitioning will require a dialogue among countries and partners on multiple fronts, including the level of ownership by countries of polio assets and for what new purposes they will be used, and discussion about cofinancing, administration, oversight, and accountability frameworks."

The term "polio legacy" refers to the investments made in polio eradication that can be shifted to meet other crucial health goals. This article provides an update on efforts to plan for a polio-free world and build on the knowledge, lessons learned, and assets of the polio eradication initiative. The premise is that the global health community has an obligation to ensure that these lessons and the knowledge generated from the experience are shared and contribute to real, sustained changes in the approach to global health.

As is reported here, the initiative is engaged in an extensive transition process of consultations and planning at the global, regional, and country levels spearheaded by the Polio Legacy Management Group set up by the Polio Oversight Board (comprising leaders of the initiative's 5 core partners: the WHO, UNICEF, the CDC, Rotary International, and the Bill & Melinda Gates Foundation) to manage the polio legacy process. This group has organised essential lessons learned from global polio eradication efforts as follows, with categories/subcategories:

• Mobilising political and social support - includes social mobilisation and advocacy, and communications and community engagement.
• Strategic planning and policy development - includes: multiyear strategic plans and planning processes; technical advisory bodies and policy processes (national, regional, and global); and national, state, and subnational task forces to guide and implement strategy.
• Partnership management and donor coordination - includes: Global Polio Eradication Initiative (GPEI) architecture (managing a global public-private partnership); interagency coordinating committees; financial resource requirements and cash flow management; and resource mobilisation and advocacy.
• Programme operations and tactics - includes: global surveillance and response capacity, including global laboratory network; mapping communities (microplans); evidence-based decision making; accountability frameworks; research and development; outreach; surveys (monitoring and evaluation); data management; vaccination teams (recruitment, training, monitoring, and payment); precampaign and in-process monitoring of activities; and workforce development (building a trained and motivated health workforce).
• Oversight and independent monitoring - includes: performance indicators; global and regional certification commissions; and the independent monitoring board.

There are 3 principal aspects of the polio legacy work: (i) maintaining and mainstreaming essential polio eradication functions, such as immunisation, surveillance, communication, response, and containment, into ongoing public health programmes in a polio-free world following the conclusion of the initiative; (ii) documenting how polio infrastructure contributes to other immunisation and public health priorities, which is referred to here as "Legacy in Action". "Each country has unique circumstances and experiences, and each would benefit from doing its own 'Lessons Learned' documentation exercise; and (iii) transitioning the capacities, processes, and assets - including human resources that the initiative has created and engaged for polio eradication - to support other health priorities, where feasible, desirable, and appropriate.

The initiative has developed transition guidelines and a toolkit of additional resource information, including guidelines on documentation of lessons learned to assist countries in completing legacy planning, which are available on the initiative's website. These guidelines recommend a 12- to 18-month process for developing and reaching consensus on national transition plans, and initiating and executing the transition plans within 6 months of completion of the consensus process until the new assets and infrastructure are fully operational. Most countries that have already eradicated polio are well into the legacy transition. It is noted here that stakeholder engagement in polio legacy transition planning should include the World Health Assembly and the regional committee meetings of the WHO's regional offices.

The article highlights the essential lessons and knowledge that the authors believe cannot afford to be lost as a result of poor legacy transition planning:

1. Other global immunisation and health priorities can benefit from the accumulated knowledge and best practices on communication and community engagement, mobilising social and community support for vaccination, and using a targeted disease elimination initiative such as polio eradication as a springboard for broader health communication.
2. Polio eradication efforts have highlighted the value of an advanced, state-of-the-art global, regional, and national laboratory network for real-time disease detection and response.
3. The knowledge and experience garnered from polio eradication efforts provide important lessons on how to reach every child, including the most underserved, migrants, nomads, people living in conflict zones, and others marginalised by circumstances that prevent or impede access to health services.
4. There are examples of outstanding programme monitoring and the use of accountability frameworks to assess performance in polio eradication.
5. Partnership coordination, advocacy, and resource mobilisation were essential to achieving polio eradication goals and can be drawn on to move forward on other global health challenges, such as the effort to wipe out the measles virus.

As noted here, in Nigeria, the experience with the use of the polio assets and infrastructure to shut down the Ebola outbreak in its early phases through aggressive surveillance, case investigation, and contact tracing is an example of the benefits of leveraging existing capabilities to tackle a different infectious disease. In contrast, the 3 other West African Ebola-affected countries provide a cautionary note of what can happen in the absence of these kinds of assets, capacity, and experience.

Although there are remaining challenges and threats to successfully completing polio eradication, "it is time for polio legacy planning to proceed with all due speed....[T]he transition of polio assets to the combination of measles eradication and immunization system strengthening makes the most sense because the diseases have similar strategies and program implementation infrastructure needs." Transitioning will require the concerted collaboration and interaction of many partners and stakeholders, together with countries, at the global, regional, and country levels. "Under the leadership of the national governments, a broad range of stakeholders must be involved in the polio legacy planning process at the country level, including donors and civil society....Enabling long-term transitions to country ownership of basic public health functions, wherever possible, will be a priority for the polio legacy planning process."