Pakistan Polio Eradication Initiative National Emergency Action Plan 2021-2023

"[T]he guiding principles for this NEAP are strong government ownership, the One Team model, staff empowerment, an urgency mindset, transparency and accountability, and approaches tailored to local contexts."

Due to the COVID-19 pandemic, the Pakistan polio programme ("the Programme") faced several challenges, including interruption of mass immunisation activities in the first half of 2020. In January 2021, a wild poliovirus type 1 (WPV1) case was reported in Killa Abdullah, Balochistan Province. The Pakistan Polio Eradication Initiative National Emergency Action Plan (NEAP) 2021-2023 has been developed with this epidemiological context in mind, with the goal of permanently interrupting transmission of all polioviruses in the polio-endemic country by the end of 2023. A key focus of the NEAP is on reducing the number of children missed by supplementary immunisation activities (SIAs) by enhancing basic SIA and outbreak response operations, directly engaging families and communities of persistently missed children through specific influencers, and allocating locally acceptable frontline workers (FLWs) to the task.

Guided by the principles encompassed in the opening quotation, above, the NEAP is structured around seven key programme priorities:

1. Strong government commitment and oversight: At every level, the government will take greater responsibility and accountability for the success of the Programme, with appropriate decision rights allocated, and with support and technical advice from partners.
2. Proficient and empowered district teams supported by emergency operations centres (EOCs): Key components include: programme management structures; clearly defined decision-making rights; performance management; and capacity building.
3. Risk assessment, programme monitoring, and data for action: The purpose of these efforts is, for example, to identify and hone in on districts that are at very high risk of WPV due to high levels of oral polio vaccine (OPV) refusal. An example of a research approach: Prioritise participatory and appreciative inquiry "listening sessions" in super-high-risk UCs (SHRUCs), very-high-risk, and high-risk districts, and strengthen cluster-level social analysis for all missed children - beyond refusals.
4. Reaching missed children - through:
   • Campaign implementation: Annually, three national immunisation days (NIDs) and three supplementary NIDs (SNIDs) will be implemented across all districts, in addition to required case responses. To ensure ample time for campaign preparation, communication, and community engagement, the SIA schedule will be spaced so there will be an average 7-week interval between campaigns.
   • Communication and community engagement (see Table 3 (pages 21-25): Operations and Community Engagement Activities by Campaign Phase and District Risk Category and Table 4 (page 25) Priority C4E Activities 2021-2023): The overarching goal of the communication for development (C4D) approach, including media and advocacy aeas of work (AoWs), is to sustain positive social norms for vaccination throughout the country and increase vaccine acceptance in high-risk areas. Priority community engagement (PCE) will involve, for example, integrating media and public communication approaches at different levels to re-position and reinforce polio eradication as a national public cause for the protection of children and to reduce refusals by creating a conducive environment for FLWs to vaccinate children at the doorstep. It will be important to address issues of concern to specific communities through targeted efforts to build trust in the programme and integrate local influencer endorsements and announcements. Key approaches to achieve these objectives include:
     • Ensure seamless operation of the COMNet (Communication Network) structure with SIA implementation.
     • Leverage community influencers' support for social mobilisation and community engagement activities that build caregiver and family knowledge, awareness, and motivation in support of polio vaccination.
     • Involve religious support persons (RSPs) to conduct advocacy sessions and meetings at Masajid, Madaris, and refusal-cluster-centred social gatherings, in addition to facilitating Friday sermons in every Friday congregation.
     • Engage mass media, social media, and press (e.g., integrate organic, external messaging from advocates outside of the programme to handle negative propaganda).
     • Engage influencers, such as locally trusted Pashtun non-governmental organisations (NGOs) and community-based organisations (CBOs), for advocacy and action in marginalised areas.
   • High-risk and mobile populations: For example, review and strengthen communication strategies, including ensuring district-to-district coordination, mapping key influencers in border areas, and engaging in community-led activities on respective sides of the Pakistan and Afghanistan border.
   • Afghanistan-Pakistan bilateral coordination For example, conduct joint data analysis between Pakistan and Afghanistan (surveillance, essential immunisation, SIA, high-risk and mobile population movement data, social profiling) to guide the identification of challenges and guide action.
   • Vaccine cold chain and logistics management. For example, provide support to the Expanded Programme on Immunization (EPI) to authorise and approve of novel OPV2 (nOPV2) - specifically, the completion of readiness documents and submission to the GPEI.
   • Training and guidelines/tools development: For example, develop training guidelines and video tutorials to build the capacity of trainers and FLWs.
   • Programme monitoring & evaluation (M&E): The monitoring approach for SIAs is outlined in Table 5, and priority M&E activities by district epidemiological risk category are outlined in Table 6 (see pages 26-27).
5. Certification-level surveillance: While only one WPV case was reported in 2021 in Pakistan as of week 48, 63 positive environmental surveillance (ES) samples tested positive for WPV. The surveillance team will need to beef up its efforts to meet the challenge of orphan viruses so as to demonstrate that, as the Programme works toward eventual polio-free certification, "zero" really means "zero".
6. Outbreak preparedness and response: During this NEAP period, the Programme will establish an outbreak group to conduct risk assessment and initial notification, investigation, and response management.
7. Targeted risk-based interventions: It has long been recognised that a significant number of refusals are based on families' and communities' dissatisfaction with being offered only polio vaccination and not other basic health care and social services. The Integrated Services Deliver (ISD) component of the Programme is designed to address that issue - e.g., through health Promotion and awareness-raising for integrated services at health camps.

In line with the GPEI Gender Equality Strategy 2019-2023, this NEAP is making efforts to strengthen the Programme's gender responsiveness by mainstreaming gender at various stages of programme planning and design, implementation, and M&E - addressing gender-related barriers to vaccination and the empowered engagement of women. The following are the priority:

• Increase ownership of and accountability for mainstreaming gender considerations into all aspects and levels of the programme via: a 15% increase in female staff every year, a formal GPEI partner coordination mechanism on gender, and data collection and analysis to complement quantitative data with robust qualitative social data, especially through the community engagement workstream.
• Create a safe work environment for all staff and contractors and enforce GPEI policies on protection from sexual exploitation and abuse (PSEA) and zero tolerance policy for perpetrators of incidents via: training of all staff on gender and PSEA by end of 2022, 100% investigation and resolution of all SEA incidents reported, and specific field-level mechanisms to prioritise the safety of polio workers and beneficiaries.