A Qualitative Exploration of the Contributions of Polio Eradication Initiative to the Nigerian Health System: Policy Implications for Polio Transition Planning

"[T]here are potential opportunities to optimize the polio legacy to achieve successful implementation of maternal and child health interventions and improve the health system of the country..."

Since the implementation of the Global Polio Eradication Initiative (GPEI) in Nigeria, there has been over a threefold increase in the national infant immunisation rates. Polio strategies have had a variety of other beneficial effects, ranging from improving communication channels between healthcare providers and members of the community, to setting up sensitisation platforms that provide information on other vaccine-preventable diseases, mapping communities and settlements in hard-to-reach areas, and engaging communities in micro-planning of health interventions, among others. However, the effect of the GPEI on the functioning of other health programmes within the health system has been in some cases contradictory, especially in countries with weakened primary health systems or across individual underfunded programmes. Thus, this study explored the contributions of the Polio Eradication Initiative (PEI) activities to the operations of other health programmes within the Nigerian health system from the perspectives of frontline workers and managers. The research was part of a more extensive study, the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE), conducted in 2018 (for example of one of the outputs, see Related Summaries, below).

The cross-sectional qualitative study covered all tiers of health delivery from the point of view of health workers who have been involved continuously in PEI activities for at least 12 months since the programme's inception, a period spanning about three decades (1988 to 2018). They comprised individuals working with the government of Nigeria, polio emergency operation centres (EOCs), the National Primary Health Care Development Agency (NPHCDA), multilateral agencies such as the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO), and international non-governmental organisations (NGOs) [Rotary International, Bill & Melinda Gates Foundation, United States Centers for Disease Control and Prevention (CDC), Nigeria Stop Polio Program (NSTOP), and a civil society group (CORE Group Polio Project)]. The government officials interviewed were those at the three tiers of healthcare delivery (i.e., the federal, state, and local government levels) who were engaged in polio eradication activities.

Specifically, 29 key informant interviews (KIIs) were conducted using a KII tool focused on these themes (illustrated in the paper with quotations from participants):

• Health workers' perception of the benefits and challenges of combining polio eradication activities with routine immunisation programmes and other health programmes: Respondents stated that working within the polio programme has equipped them with both hard and soft skills that have been useful for other health programmes, though there have been difficulties. See Table 2 in the paper for a summary of the perceived benefits and challenges with illustrative quotes.
• Similarities and distinctions between PEI, routine immunisation, and other health programmes: The similarities between PEI and other health programmes are highlighted in Box 2 in the paper; Box 3 summarises PEI's advantage over other health programmes. The distinctions that were reported arise from the sense of urgency associated with polio eradication activities in the country. For instance, there is increased community engagement and collaboration between the partners and the government institutions to ensure that the poliovirus is eradicated. This emphasis is not as pronounced in other health programmes.
• Positive contributions of the PEI to health programmes: Respondents noted that resources, training, knowledge, experience, and innovations from the PEI are useful for other health programmes and for strengthening the health system. For example, a frontline health worker discussed the use of health camps during polio programmes to promote healthy behaviour in the community, indicating that this strategy - where community members gather with health workers in a designated location to be educated and vaccinated - may be adopted for other health programmes. Another interviewee spoke about the adoption of experiences in community mobilisation and dialogue from the polio programme in improving coverage in other health programmes. Lessons applied to other programmes ranged from the utilisation of existing polio physical structures (the EOC - e.g., during the 2014 Ebola crisis) to social structures (religious and traditional leaders) and technology (geographic information system). A respondent from a partner organisation highlighted that the advocacy skills from the polio programme have been useful for other health initiatives.
• Negative unintended consequences of PEI on other health programmes in Nigeria: Some respondents noted that the major adverse effect of the polio programme on the health system is shifting the attention of the health workers from their primary roles and responsibilities to the polio campaigns.
• Missed opportunities for other programmes to leverage the polio programme: Examples include the supervision of field activities in maternal, HIV, and malaria programmes.

In short: "Health systems with structural deficiencies in low-income countries, such as the Nigerian health system, can exploit vertical initiatives such as the PEI program to eliminate gaps in access to health....The PEI adopts strategies of house-to-house immunization, use of community members as informants engaging in social networks with the community, advocacy, etc...[i]nstead of attempts to incorporate policies within the wider health sector. These target-specific programs like the PEI are likely to produce rapid results in terms of meeting national and international goals on pressing health issues. However, it is difficult to manage such intensive systems in the long run without preventing negative spillovers....[T]he potential for major service interruption will be greatly felt by community members who depend on [rural] health workers as they quit their duty posts during the campaign days to engage in supplementary immunization programs due to the financial incentives from the program....The PEI program has struggled to address these negative spillover effects by championing the integration of the health system through PHC [primary health care] under one roof."

In conclusion, this study has highlighted the Nigerian PEI's contribution to other health programmes in the country, including "the substantial improvement in the capacity of the primary health care workers and improved community confidence in the health system. The latter was mainly due to the development of structures linking the community with the primary health care system....Implementers of other disease elimination and control programs can leverage lessons learned from the Polio Eradication Initiative to achieve their implementation goals more effectively and efficiently."