<div dir="ltr"><div class="gmail_default" style="font-size:large"><br></div>From: <b class="gmail_sendername" dir="auto">David</b> <span dir="auto"><<a href="mailto:dlegge@phmovement.org">dlegge@phmovement.org</a>></span><br><div class="gmail_quote"><br><br><u></u>
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<span class="m_-6694170463282507243mcnPreviewText" style="display:none;font-size:0px;line-height:0px;max-height:0px;max-width:0px;opacity:0;overflow:hidden">"The 'last mile' is difficult and expensive" - The understatement of the WHA72</span>
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<td class="m_-6694170463282507243mcnTextContent" style="padding-top:0;padding-right:18px;padding-bottom:9px;padding-left:18px;word-break:break-word;color:#202020;font-family:Helvetica;font-size:16px;line-height:150%;text-align:left" valign="top">
<h1 class="m_-6694170463282507243null" style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:26px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Low income countries face cut back in international assistance as polio campaign looks towards winding down</h1>
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 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=03ab90a78e&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/34</a>). So what happens to polio funding (which is already starting to reduce, see <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b85b107f18&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/INF./3</a>) when polio eradication is finally declared. (A final declaration of polio eradication was scheduled for 2019 but has now been deferred to 2023; see <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d54888c6c2&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/9</a>).<br>
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Transition planning (see <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=cab6b8768c&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/10</a> and also <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=1e580b2f21&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/INF./3</a>) raises difficult issues regarding human resources, health service delivery and funding flows.<br>
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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.)<br>
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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.<br>
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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 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=adbc341f57&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/10</a>) 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.)<br>
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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 (<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=7ebc41d75f&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>) 'private sector/non-government donors' have funded 33% of GPEI expenditure.<br>
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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.<br>
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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".<br>
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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".<br>
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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.<br>
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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 (<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3fc356bfc9&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/INF./3</a>). 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'.<br>
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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.
<h2 class="m_-6694170463282507243null" style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">'Global health security' distorts international assistance for health</h2>
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.<br>
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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 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=cd0d66c870&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">CIA agents posing as health workers</a>) 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.<br>
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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.<br>
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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.
<h2 class="m_-6694170463282507243null" style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Immunisation the key</h2>
Polio eradication (<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=422193797c&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">A72/9</a>) 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.<br>
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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 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=31a55ce3ac&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">March statement </a>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.
<h2 class="m_-6694170463282507243null" style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Shortages, price barriers and health systems capacity</h2>
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.<br>
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.<br>
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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).<br>
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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 <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=127c95d0ca&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">March statement </a>of the IHR Emergency Polio committee).<br>
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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.
<h2 class="m_-6694170463282507243null" style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Conclusions</h2>
In the short term the critical task is to finally achieve eradication.<br>
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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.<br>
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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.<br>
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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'.<br>
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For full coverage of the WHA debate over Polio see the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=808e5c9bf9&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">PHM item commentary</a>, which includes the WHO watchers' notes of the debate.<br>
Access all of the papers and debates from the World Health Assembly from the WHO Tracker at <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=60daea4141&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">who-track.phmovement.org/wha72</a>. Review previous Update Reports <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=54a6b8f2f9&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>.
<h2 class="m_-6694170463282507243null" style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Spread the word</h2>
<p style="margin:10px 0;padding:0;color:#202020;font-family:Helvetica;font-size:16px;line-height:150%;text-align:left">The purpose of WHO Watch (and the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=47049a0bf9&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Tracker</a>) is to contribute to democratising global health governance, through new alliances and new information flows. You can help by forwarding our updates, disseminating on social media and inviting others to <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d4b7b82d14&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">subscribe to the Updater</a>.<br>
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WHO Watch is a project of the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b70828eda2&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">People's Health Movement</a> in cooperation with <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=0a7530b6a1&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Medicus Mundi International</a>, <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=4da91612f1&e=916df65fd1" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Third World Network</a> and a number of other civil society networks.<br>
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