PHM-Exch> Low income countries face cut back in international assistance as polio campaign looks towards winding down

[Claudio Schuftan]

From: David <dlegge at phmovement.org>


"The 'last mile' is difficult and expensive" - The understatement of the
WHA72

Low income countries face cut back in international assistance as polio
campaign looks towards winding down Transition was the key word in the
recent World Health Assembly (WHA) debate over the wind-down of the Global
Polio Eradication Initiative (GPEI). Polio now accounts for around 20% of
total WHO expenditure (see A72/34
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=03ab90a78e&e=916df65fd1>).
So what happens to polio funding (which is already starting to reduce, see
A72/INF./3
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b85b107f18&e=916df65fd1>)
when polio eradication is finally declared. (A final declaration of polio
eradication was scheduled for 2019 but has now been deferred to 2023; see
A72/9
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d54888c6c2&e=916df65fd1>
).

Transition planning (see A72/10
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=cab6b8768c&e=916df65fd1>
and also A72/INF./3
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=1e580b2f21&e=916df65fd1>)
raises difficult issues regarding human resources, health service delivery
and funding flows.

For WHO management there is an immediate indemnity risk associated with the
costs of paying out retrenched polio funded staff if there is a net
reduction in funds. (This indemnity risk has been recognised by WHO for
several years but was highlighted again by the UK in the recent WHA debate.)

The other side of this indemnity risk is the threat of losing a huge cadre
of health workers (presently funded under polio) whose contribution to
immunisation generally and a range of other PHC functions is critical. This
threat was highlighted by Brazil and Germany in particular. Germany
highlighted the need for polio funding to be transitioned into health
system strengthening, including the incorporation of immunisation and
disease surveillance into national health programs.

Thus 'transition' encompasses the operational challenge of transferring
polio staff into more generic national programs (immunisation,
surveillance, public health, primary health care) but also maintaining the
necessary funding flows. It is most unlikely that low income countries who
have large polio programs will be able to fund this transition through
domestic resources. (WHO reports (in A72/10
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=adbc341f57&e=916df65fd1>)
that the development of costed national transition plans has been slower
than had been hoped and that many polio transition countries will not be
able to achieve transition without continued international funding.)

Many contributors to the WHO debate over transition highlighted the
uncertainty about continuity of funding. Almost half of GPEI expenditure in
2018 was funded by 'private sector/non –government donors', a category
dominated by the Gates Foundation. Over the period 1985-2018 (here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=7ebc41d75f&e=916df65fd1>)
'private sector/non-government donors' have funded 33% of GPEI expenditure.

During the WHA debate India urged continued funding after eradication
arguing that downsizing the programs established under the GPEI will impact
on the control of other vaccine preventable diseases. Niger called for
increasing support for primary health care towards universal health
coverage and for funding support to prevent maternal deaths and improve
child health. Pakistan highlighted the importance of safe water as part of
containing polio spread but with far reaching health benefits beyond polio.

However the USA downplayed the discussion of 'transition' urging that "the
world’s focus should be on eradication as without that there will be no
transition".

Japan recognised that previously polio-funded staff could be deployed in
disease surveillance and health system strengthening. However, Japan argued
that as funding falls off strategic decisions will be needed regarding
which functions to keep "but we can't keep everything so we need to assess
what to keep".

GAVI emphasised the importance of accelerating nationally-owned transition
plans and indicated that "time-limited bridge-funding" would be available
to facilitate transition and absorption of essential routine immunisation
functions into national budgets.

Meanwhile WHO has transferred a large slice of previously ring-fenced polio
funding into its 'base budget'. By 2023 23% of total 'polio' funding will
flow through WHO's base budget (A72/INF./3
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3fc356bfc9&e=916df65fd1>).
WHO says that this "reflects WHO’s commitment to ongoing support for
critical core public health functions that are currently financed by the
Initiative". However, this transfer will have been negotiated with the
donors since GPEI expenditure has been based solely on donor funding. The
funds flowing through WHO's base budget are still totally dependent on the
willingness of the donors and the conditions of their funding.  Not all
member states are fully comfortable with this transfer of GPEI funding into
WHO's base, with Mexico and Thailand expressing concerns regarding
'duplication'.

Polio funding has been dominated by Gates and G7 donors. It remains to be
seen how much of this funding will continue to flow once eradication has
been declared. 'Global health security' distorts international assistance
for health The cost of polio eradication, when it comes, will have been
huge. Norway and Pakistan and the DG all referred to the cost of the 'last
mile' in their interventions in the WHA debate. Expressed in relation to
the prevailing burden of disease the cost of the 'last mile' is
astronomical. However, given the huge investment in polio eradication to
this point the logic of traveling the last mile is widely accepted.

Eradication (of wild type polio) now depends largely on surveillance and
immunisation in Afghanistan, Pakistan and Northern Nigeria. Conflict, weak
health systems, and suspicion of immunisation teams (particularly since the
assassination of Osama Bin Laden on the basis of intelligence collected by CIA
agents posing as health workers
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=cd0d66c870&e=916df65fd1>)
has seen continued transmission of disease and the failure to achieve the
deadline for eradication, as well as the tragic loss of life by frontline
health workers.

Mexico spoke what many were thinking when it commented on the opportunity
costs of the huge expenditure on polio eradication as compared with other
priorities such as NCDs, clean water, sanitation and malnutrition.

Public health distinguishes between disease control (achieving a low
incidence or prevalence), disease elimination (from particular
geographies), and disease eradication ('everywhere, for ever'). The
politics of disease eradication are commonly illustrated with reference to
the failure of malaria eradication (in the 1950s) and the successful
eradication of small pox (declared in 1980). These histories are deeply
entwined with geopolitics and military logics which invites questions about
the long range politics of polio eradication: magic bullet, eradication as
trophy, investment in 'global health security', legitimation ploy; perhaps
in some degree, an expression of human solidarity.  Immunisation the key
Polio eradication (A72/9
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=422193797c&e=916df65fd1>)
requires complete interruption of wild type poliovirus transmission which
depends largely on immunisation; achieving high levels of herd immunity.
Maintaining high rates of immunisation in the remaining polio prevalent
countries (Afghanistan, Pakistan and Nigeria) has faced continuing barriers
associated with conflict, war, displacement, weak health systems, and
fragile states.

It has been further complicated by the emergence of vaccine derived polio,
largely associated with the Type 2 polio virus used in attenuated (live)
form in the oral polio vaccine.  WHO reports (see March statement
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=31a55ce3ac&e=916df65fd1>of
the IHR Emergency Polio committee) that there are now eight countries in
two regions which have experienced outbreaks of circulating vaccine-derived
poliomyelitis (including Type 1 in Indonesia and PNG; and Type 2 in
Mozambique, Nigeria, Benin, Sudan, Kenya and DRC). In order to prevent the
emergence and transmission of vaccine derived illness, oral polio vaccine
is being withdrawn and replaced with inactivated vaccine (IPV) which
requires injection rather than oral drops. Priority has been assigned to
withdrawing Type 2 vaccine (OPV2) and replacing it globally with IPV2.
Shortages,
price barriers and health systems capacity The shift to IPV2 has been
complicated by vaccine shortages and significant price barriers. Gabon,
speaking for all of the countries of the African region, advised that
obtaining sufficient IPV has been challenging. Niger also complained about
access to affordable vaccines.
India reported an 80% hike in the cost of vaccines and called for the
strengthening of market mechanisms to control the prices of vaccines,
clearly a reference to the ongoing transparency debate.

Thailand commented on the cost of new IPV vaccines (and in passing
criticised WHO's approach to recommending the inclusion of new vaccines in
national immunisation schedules).

Several countries commented on weak health systems, in particular, weak
primary health care, as barriers to universal immunisation. Mozambique
reported that it was struggling to deliver high levels of immunisation; in
some regions coverage was as low as 14%. This helps to explain the new
outbreak of cVDPV2 in Mozambique, (mentioned in the March statement
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=127c95d0ca&e=916df65fd1>of
the IHR Emergency Polio committee).

Ghana commented on its investment in an integrated health system response
to polio. Cuba which has invested in developing a strong PHC system over
many years, advised that polio eradication had been certified in
1996. Japan commented on the role of decent PHC in addressing community
concerns about immunisation. Conclusions In the short term the critical
task is to finally achieve eradication.

In the medium-term there are critical issues to be addressed in terms of
transferring polio funding to national health budgets for health system
strengthening, including immunisation and disease surveillance.

In the longer term low income countries will continue to confront huge
challenges in health system strengthening, universal immunisation and
affordable access to medicines and vaccines.

The polio story also needs to be seen in a longer term historical
perspective, alongside malaria and smallpox. This perspective provides
useful insights into the geopolitics of international public health,
including the politics of 'global health security'.


For full coverage of the WHA debate over Polio see the PHM item commentary
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=808e5c9bf9&e=916df65fd1>,
which includes the WHO watchers' notes of the debate.
Access all of the papers and debates from the World Health Assembly from
the WHO Tracker at who-track.phmovement.org/wha72
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=60daea4141&e=916df65fd1>.
Review previous Update Reports here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=54a6b8f2f9&e=916df65fd1>.
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