《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2003_Shaping the Future_Chapter4 Polio Eradication：the final challenge

Chapter Four Polio eradication the final challenge As a result of the global polio eradication initiative. one of the largest public health efforts in history, the number of chil- dren paralysed by this devastating disease every year has fallen from over 350 000 in 1988 to as few as 1900 in 2003 the number of endemic countries has fallen from over 125 to seven. This chapter records the final phase of the campaign to eradicate one of the oldest known diseases the vision of a polio-free world is now within reach

Polio Eradication: the final challenge 57 Chapter Four Polio Eradication: the final challenge As a result of the Global Polio Eradication Initiative, one of the largest public health efforts in history, the number of chil￾dren paralysed by this devastating disease every year has fallen from over 350 000 in 1988 to as few as 1900 in 2003; the number of endemic countries has fallen from over 125 to seven. This chapter records the final phase of the campaign to eradicate one of the oldest known diseases. The vision of a polio-free world is now within reach

Polio eradication the final challenge In 1962, just 12 months after Albert Sabins widely hailed oral polio vaccine(OPv) was li- censed in most industrialized countries, Cuba began using the vaccine in a series of nation ide polio campaigns. Shortly thereafter, indigenous wild poliovirus transmission had been rrupted. In other words, no Cuban child would ever again suffer this devastating di as the result of a Cuban poliovirus. Seldom, if ever, had a new health technology been exploited so successfully and so early in its lifespan, to the benefit of so many people countries were to experience such early successes, however, as polio continued to paralyse permanently half a million people every year -even by the 1990s between 10 and 20 million people who had survived the acute illness were living with its debilitating and often painful consequences. For Sabin, however, Cuba's experience with mass campaigns had reaffirmed his conviction that polioviruses could be eradicated so completely that future generations would know polio paralysis only through history books. Sabin,'s way of shaping that future without polio was to donate his vaccine to the World Health Organization so that it might be made available to all peoples, everywhere. Forty years later, the world is on the verge of realizing Sabins global vision of a future with out polio. Through an extraordinary 15-year international effort, indigenous polioviruses have now been eliminated from all but seven countries, down from over 125 when the initia- tive began(1)(see Figure 4.1). This progress is the result of a unique partnership forged between governments, international agencies, humanitarian organizations and the private sector to take up three key challenges to reaching all children, everywhere: effective engage ment of political leaders, adequate financing, and sufficient human resources. Through this partnership, over 10 million volunteers immunized 575 million children against polio in 9 of the lowest-income countries in the world in the year 2001 alone. This experience, and the prospects for the completion of polio eradication, provide insights for scaling up access to other health interventions, a process that will be essential to achieving ambitious national and international health targets such as those adopted in the Millennium Development Goals( 2) A new kind of partnership As international interest in a global effort to eradicate polio began to build up 20 years ago, there was limited experience with large-scale international health initiatives and with part nerships. In the mid-1980s, however, as an increasing number of countries in South America most notably, Brazil-successfully applied the Cuban model of mass campaigns and height- ened surveillance to control polio, a new kind of partnership began to emerge with this common purpose

Polio Eradication: the final challenge 59 4 Polio Eradication: the final challenge In 1962, just 12 months after Albert Sabin’s widely hailed oral polio vaccine (OPV) was li￾censed in most industrialized countries, Cuba began using the vaccine in a series of nation￾wide polio campaigns. Shortly thereafter, indigenous wild poliovirus transmission had been interrupted. In other words, no Cuban child would ever again suffer this devastating disease as the result of a Cuban poliovirus. Seldom, if ever, had a new health technology been fully exploited so successfully and so early in its lifespan, to the benefit of so many people. Few countries were to experience such early successes, however, as polio continued to paralyse permanently half a million people every year – even by the 1990s between 10 and 20 million people who had survived the acute illness were living with its debilitating and often painful consequences. For Sabin, however, Cuba’s experience with mass campaigns had reaffirmed his conviction that polioviruses could be eradicated so completely that future generations would know polio paralysis only through history books. Sabin’s way of shaping that future without polio was to donate his vaccine to the World Health Organization so that it might be made available to all peoples, everywhere. Forty years later, the world is on the verge of realizing Sabin’s global vision of a future with￾out polio. Through an extraordinary 15-year international effort, indigenous polioviruses have now been eliminated from all but seven countries, down from over 125 when the initia￾tive began (1) (see Figure 4.1). This progress is the result of a unique partnership forged between governments, international agencies, humanitarian organizations and the private sector to take up three key challenges to reaching all children, everywhere: effective engage￾ment of political leaders, adequate financing, and sufficient human resources. Through this partnership, over 10 million volunteers immunized 575 million children against polio in 93 of the lowest-income countries in the world in the year 2001 alone. This experience, and the prospects for the completion of polio eradication, provide insights for scaling up access to other health interventions, a process that will be essential to achieving ambitious national and international health targets such as those adopted in the Millennium Development Goals (2). A new kind of partnership As international interest in a global effort to eradicate polio began to build up 20 years ago, there was limited experience with large-scale international health initiatives and with part￾nerships. In the mid-1980s, however, as an increasing number of countries in South America – most notably, Brazil – successfully applied the Cuban model of mass campaigns and height￾ened surveillance to control polio, a new kind of partnership began to emerge with this common purpose

The World Health Report 2003 By 1988, the year in which the World Health Assembly voted to launch a global initiative to eradicate polio(3), four agencies had begun to form the core of the"polio partnership": the World Health Organization, Rotary International, the United Nations Childrens Fund (UNICEF)and the United States Centers for Disease Control and Prevention(CDC). Over the following 15 years, the polio partnership has grown to become an extensive network of national governments, international agencies, private corporations, foundations, bilateral do- nors, humanitarian organizations, nongovernmental organizations and development banks The work of the partnership continues to be governed by a common, multiyear strategic plan and overseen by international technical committees at the country, regional and global levels The close relationship between national health authorities and this international partnership was critical to the extremely rapid scaling-up of eradication activities in the mid-1990s, as the initiative began building on the early momentum in the Americas and the Western Pacific Region and extended its activities to all countries of all regions By the end of the decade, over 500 million children were regularly being reached with OPV through the efforts of 10 million volunteers in every low-income and middle-income country in the world. From the outset, this partnership sought to bring a new efficiency to international support for national health efforts. It relied heavily on strategies and management processes that had been established by the Pan American Health Organization(PAHO)in its work to achie regional elimination of polio. This goal was realized in 1991, when a young Peruvian boy named Luis Fermin Tenorio became the last child ever to be paralysed by a wild poliovirus in the Region of the Americas. The global partnership adopted PAHOs proven four-pronged strategy: high coverage with routine OPV immunization, national polio immunization days, surveillance and laboratory investigation of acute flaccid paralysis(AFP)cases, and massive house-to-house"mop-up"campaigns(4). PAHOs Interagency Coordinating Committee (ICC)mechanism brought together partner inputs at the country level to ensure sufficient resources, while promoting transparent budgeting and efficiencies. The ICCs, convened regu larly by national ministries of health, ensured that national authorities were always at the centre of key decisions on strategy implementation. The global partnership also emphasizes engagement at the highest political levels in both donor and endemic countries Effectively engaging political leaders The most visible element of the polio eradication initiative has been the National Immuniza- tion Days(NIDs), as they require the immunization of every child under 5 years of age(nearly 20% of a country's population)over a period of 1-3 days, several times a year for a number of years in a row. In many countries, the scale and logistic complexity of these activities were even greater than those of campaigns undertaken during the height of the smallpox eradica tion effort. Consequently, the commitment of political leaders has been central to their suc- cess.This support has been generated by actively and continuously advocating for such leaders to play a role in three key areas: oversight, access to non-health resources, and accountability. The oversight of polio activities by political leaders has often begun with their personal pa ticipation in highly visible events such as the launching of NIDs and, ideally, has continued with their monitoring of progress. Following the example of South America, most countries have had their NIDs launched by the head of state or other prominent political figure. For example, in China, President Jiang Zemin immunized the first child in the national polic campaign in 1993. In the same year, King Sihanouk played a similar role in Cambodia. In 1996, President Nelson Mandela of South Africa launched the "Kick polio out of africa campaign at the Organization of African Unity(OAU)meeting in Yaounde, Cameroon, and committed the oau to regularly monitoring progress(5). Among donor countries, polio has

60 The World Health Report 2003 By 1988, the year in which the World Health Assembly voted to launch a global initiative to eradicate polio (3), four agencies had begun to form the core of the “polio partnership”: the World Health Organization, Rotary International, the United Nations Children’s Fund (UNICEF) and the United States Centers for Disease Control and Prevention (CDC). Over the following 15 years, the polio partnership has grown to become an extensive network of national governments, international agencies, private corporations, foundations, bilateral do￾nors, humanitarian organizations, nongovernmental organizations and development banks. The work of the partnership continues to be governed by a common, multiyear strategic plan and overseen by international technical committees at the country, regional and global levels. The close relationship between national health authorities and this international partnership was critical to the extremely rapid scaling-up of eradication activities in the mid-1990s, as the initiative began building on the early momentum in the Americas and the Western Pacific Region and extended its activities to all countries of all regions. By the end of the decade, over 500 million children were regularly being reached with OPV through the efforts of 10 million volunteers in every low-income and middle-income country in the world. From the outset, this partnership sought to bring a new efficiency to international support for national health efforts. It relied heavily on strategies and management processes that had been established by the Pan American Health Organization (PAHO) in its work to achieve regional elimination of polio. This goal was realized in 1991, when a young Peruvian boy named Luis Fermin Tenorio became the last child ever to be paralysed by a wild poliovirus in the Region of the Americas. The global partnership adopted PAHO’s proven four-pronged strategy: high coverage with routine OPV immunization, national polio immunization days, surveillance and laboratory investigation of acute flaccid paralysis (AFP) cases, and massive house-to-house “mop-up” campaigns (4). PAHO’s Interagency Coordinating Committee (ICC) mechanism brought together partner inputs at the country level to ensure sufficient resources, while promoting transparent budgeting and efficiencies. The ICCs, convened regu￾larly by national ministries of health, ensured that national authorities were always at the centre of key decisions on strategy implementation. The global partnership also emphasizes engagement at the highest political levels in both donor and endemic countries. Effectively engaging political leaders The most visible element of the polio eradication initiative has been the National Immuniza￾tion Days (NIDs), as they require the immunization of every child under 5 years of age (nearly 20% of a country’s population) over a period of 1–3 days, several times a year for a number of years in a row. In many countries, the scale and logistic complexity of these activities were even greater than those of campaigns undertaken during the height of the smallpox eradica￾tion effort. Consequently, the commitment of political leaders has been central to their suc￾cess. This support has been generated by actively and continuously advocating for such leaders to play a role in three key areas: oversight, access to non-health resources, and accountability. The oversight of polio activities by political leaders has often begun with their personal par￾ticipation in highly visible events such as the launching of NIDs and, ideally, has continued with their monitoring of progress. Following the example of South America, most countries have had their NIDs launched by the head of state or other prominent political figure. For example, in China, President Jiang Zemin immunized the first child in the national polio campaign in 1993. In the same year, King Sihanouk played a similar role in Cambodia. In 1996, President Nelson Mandela of South Africa launched the “Kick Polio Out of Africa” campaign at the Organization of African Unity (OAU) meeting in Yaoundé, Cameroon, and committed the OAU to regularly monitoring progress (5). Among donor countries, polio has

Polio eradication: the final chall Figure 4.1 Endemic polio in 1988 and mid-2003 1988 Endemic >125 countrie Non-endemic 2003 Endemic 7 countries Non-endemic

Polio Eradication: the final challenge 61 Endemic Non-endemic 2003 7 countries Endemic Non-endemic 1988 > 125 countries Figure 4.1 Endemic polio in 1988 and mid-2003

The World Health Report 2003 received similar support -most noticeably when the G8 Heads of Government discussed their role in closing the funding gap for eradication activities during their meetings of 2002 and This high-level visibility has been critical to achieving the second, and perhaps most impor- tant goal of political advocacy: access to government and nongovernmental resources which lie outside the health sector. Because of the huge numbers of people and vehicles that are required to implement NIDs, such activities are beyond the logistic and communication capacity of the health sector in many countries. Consequently, countries have drawn heavily on ministries of information, transport, defence and others to help solve the challenge of rapidly reaching all children, in all corners of a country. Countries have also engaged the private sector, often on an extraordinary scale. In the Philippines, for example, more than 14 private companies have regularly donated personnel, vehicles, facilities and financial sup port. The effective mobilization of such support has been possible only when the highest political leadership, at both national and subnational levels, endorsed the initiative publicly and took the necessary steps to put these resources at the disposal of health authorities. Thus, the delivery of this health service became a government and societal responsibility, with the responsibility of the health sector moving from implementation to management and monitoring. This personal engagement of political leaders in the oversight and implementation of activi- ties leads naturally to the third goal of political advocacy: heightened accountability, both Box 4.1 Progress towards polio eradication in the Eastern Mediterranean All countries of the Eastern Mediterranean Region are rapidly progress. poliovirus, the certification of polio eradication and the development of on g towards the eradication of poliomyelitis. The number of cases has post-certification immunization policy decreased relatively regularly, as shown by the well-developed and effi National containment coordinators have been nominated in 19 of cient surveillance system. By the end of 2002, poliovirus transmission the 23 countries of the region, 16 of which have also established na- had been interrupted in 18 countries of the region for more than three tional containment committees. By the end of 2002, 18 countries had ars; in addition, Sudan has not reported a single polio case since April prepared a national containment plan; three of the remaining five coun- only four countries(Pakistan: 90: Afghanistan: 10: Egypt: 7; and Soma. has been successfully completed in seven countries and is currenty o 2001. During 2002, 110 confirmed cases of polio were reported from tries still have ongoing virus transmission. The first containment ph lia: 3). During the first eight months of 2003, 61 cases were reported ing implemented in another 11 (Pakistan: 57: Afghanistan: 2; and Egypt: 1); a further case, in Lebanon, All countries of the region except Somalia have established Na- proved to be imported and genetically linked to the virus strains from tional Certification Committees(NCCs) with appropriate membership. Eighteen countries with no viral circulation have submitted reports and Intensified national immunization days(NIDs)are continuing in national documentation to the Regional Certification Committee(RCC). 2003, with technical support from WHO, both in endemic countries which has already reviewed 15 of these reports and provided appropri- Afghanistan, Egypt, Pakistan and Somalia) and in Sudan which was ate feedback. The RCC is also reviewing annual updates provided by recently decared polio-free. All these countries conduct more than two countries whose initial reports were satisfactory. These annual updates NIDs and one or more rounds of sub-national immunization days(SNIDs) will be submitted annually until regional certification is achieved in high-risk districts each year, reaching all children through house-to. Despite the significant achievements in remaining endemic areas, house immunization. Acute flaccid paralysis(AFP) surveillance contin. the eradication programme still faces a number of challenges and con- ued to improve throughout the region. The non-polio AFP rate has further straints that must be overcome to reach the final goal. The main focus increased in 2003 to reach 2.39 per 100 000 children under 15 years of now is Pakistan, where several outbreaks occurred during 2002-2003 age, while stool specimen collection has reached 90% It seems that the youngest children in tribal and conservative populations As the polio eradication initiative moves into its final phase, tech- are likely to be missed if the vaccination team does not include a woman nical advisory groups for the priority countries regularly review the epi- In order to overcome these difficulties, the emphasis is on enlisting fed In addition, a regional technical advisory group was established to pro. target all transmission zones. New international staff are being mobi- vide leadership for eradication activities in the remaining polio-endemic lized in districts with no previously assigned consultants, to help provid countries and to advise Member States on other technical issues. In. the needed technical support to ensure high-quality performance in sur- creasing attention is being given to the laboratory containment of wild veillance in all areas

62 The World Health Report 2003 received similar support – most noticeably when the G8 Heads of Government discussed their role in closing the funding gap for eradication activities during their meetings of 2002 and 2003 (6). This high-level visibility has been critical to achieving the second, and perhaps most impor￾tant goal of political advocacy: access to government and nongovernmental resources which lie outside the health sector. Because of the huge numbers of people and vehicles that are required to implement NIDs, such activities are beyond the logistic and communication capacity of the health sector in many countries. Consequently, countries have drawn heavily on ministries of information, transport, defence and others to help solve the challenge of rapidly reaching all children, in all corners of a country. Countries have also engaged the private sector, often on an extraordinary scale. In the Philippines, for example, more than 140 private companies have regularly donated personnel, vehicles, facilities and financial sup￾port. The effective mobilization of such support has been possible only when the highest political leadership, at both national and subnational levels, endorsed the initiative publicly and took the necessary steps to put these resources at the disposal of health authorities. Thus, the delivery of this health service became a government and societal responsibility, with the responsibility of the health sector moving from implementation to management and monitoring. This personal engagement of political leaders in the oversight and implementation of activi￾ties leads naturally to the third goal of political advocacy: heightened accountability, both Box 4.1 Progress towards polio eradication in the Eastern Mediterranean All countries of the Eastern Mediterranean Region are rapidly progress￾ing towards the eradication of poliomyelitis. The number of cases has decreased relatively regularly, as shown by the well-developed and effi￾cient surveillance system. By the end of 2002, poliovirus transmission had been interrupted in 18 countries of the region for more than three years; in addition, Sudan has not reported a single polio case since April 2001. During 2002, 110 confirmed cases of polio were reported from only four countries (Pakistan: 90; Afghanistan: 10; Egypt: 7; and Soma￾lia: 3). During the first eight months of 2003, 61 cases were reported (Pakistan: 57; Afghanistan: 2; and Egypt: 1); a further case, in Lebanon, proved to be imported and genetically linked to the virus strains from India. Intensified national immunization days (NIDs) are continuing in 2003, with technical support from WHO, both in endemic countries (Afghanistan, Egypt, Pakistan and Somalia) and in Sudan which was recently declared polio-free. All these countries conduct more than two NIDs and one or more rounds of sub-national immunization days (SNIDs) in high-risk districts each year, reaching all children through house-to￾house immunization. Acute flaccid paralysis (AFP) surveillance contin￾ued to improve throughout the region. The non-polio AFP rate has further increased in 2003 to reach 2.39 per 100 000 children under 15 years of age, while stool specimen collection has reached 90%. As the polio eradication initiative moves into its final phase, tech￾nical advisory groups for the priority countries regularly review the epi￾demiological situation and national plans and provide technical advice. In addition, a regional technical advisory group was established to pro￾vide leadership for eradication activities in the remaining polio-endemic countries and to advise Member States on other technical issues. In￾creasing attention is being given to the laboratory containment of wild poliovirus, the certification of polio eradication and the development of post-certification immunization policy. National containment coordinators have been nominated in 19 of the 23 countries of the region, 16 of which have also established na￾tional containment committees. By the end of 2002, 18 countries had prepared a national containment plan; three of the remaining five coun￾tries still have ongoing virus transmission. The first containment phase has been successfully completed in seven countries and is currently be￾ing implemented in another 11. All countries of the region except Somalia have established Na￾tional Certification Committees (NCCs) with appropriate membership. Eighteen countries with no viral circulation have submitted reports and national documentation to the Regional Certification Committee (RCC), which has already reviewed 15 of these reports and provided appropri￾ate feedback. The RCC is also reviewing annual updates provided by countries whose initial reports were satisfactory. These annual updates will be submitted annually until regional certification is achieved. Despite the significant achievements in remaining endemic areas, the eradication programme still faces a number of challenges and con￾straints that must be overcome to reach the final goal. The main focus now is Pakistan, where several outbreaks occurred during 2002–2003. It seems that the youngest children in tribal and conservative populations are likely to be missed if the vaccination team does not include a woman. In order to overcome these difficulties, the emphasis is on enlisting fed￾eral, provincial and local political leaders and expanding the SNIDs to target all transmission zones. New international staff are being mobi￾lized in districts with no previously assigned consultants, to help provide the needed technical support to ensure high-quality performance in sur￾veillance in all areas

Polio Eradication: the final challenge within and outside the health sector. Only the highest-level political leadership has the neces sary authority to ensure this accountability, particularly in the non-health ministries whose personnel and resources are so important in ensuring that all children are reached with OPV. Such high-level engagement of political leaders has brought additional, often extraordinary, benefits. Recognizing that poliovirus knew no borders, in April 1995 leaders of 18 countries of Asia, Europe and the Eastern Mediterranean began coordinating the OPv immunization of 56 million children Similar activities followed in Africa. where the conflict-affected coun tries of Angola, the Democratic Republic of the Congo, Gabon, and the Republic of the Congo synchronized three rounds of NiDs from July 2001, reaching 15 million children. Through out the past 15 years, in countries such as Afghanistan, Angola, Sierra Leone and Sri Lanka, warring parties have laid down their weapons to participate in"days of tranquility"so that their children might be immunized against polio(7). Progress towards eradication in coun- tries of the Eastern Mediterranean and South-East Asia Regions is detailed in Boxes 4. 1 and 4.2 Finding the funds Sabin s vision of a world without polio required reaching all children with multiple doses of OPV, which in turn required substantial financial resources and in-kind contributions from national and international sources To mobilize and manage resources on this scale, the polio partnership established a mix of strategies and mechanisms. The success of this approach is reflected in the mobilization of more than USS 5 billion in funding and in-kind contribu- tions for polio eradication activities, over a 20-year period (8). While the majority of these funds went to time-limited eradication activities, a substantial proportion was directed to the strengthening of routine immunization and surveillance services In any given country, the proportion of costs covered by national and international sources has correlated most closely with income level and health system capacity. China, for example, has estimated that over 95% of its costs were borne by the country itself. Even in the poorest countries with virtually non-existent formal health services, such as Somalia, the community absorbs 25-50% of the real costs of implementing polio NIDs through in-kind contribu- tions. Because of the diversity of the communities, governments and partners that have Box 4.2 Responding to the challenge of polio eradication in South-East Asia In 2002, the global goal of polio eradication was jeopardized as India This progress is the result of a regionally coordinated, data-driven pro- suffered the largest outbreak in recent history: 1600 cases were reported gramme that began in the early 1990s and through which National Im that year, a fivefold increase over 2001. As the epidemic spread into munization Days have reached over 200 million children, often Indian states which had finally become polio-free in recent years, the synchronized across Member States and supported by regional bodies number of infected districts more than doubled from 63 in 2001 to 159. such as the South Asian Association for Regional Cooperation. Strong Because of India's long borders with Bangladesh and Nepal, the epi- polio surveillance and a regional network of 17 high-quality laborato demic also threatened these polio-free countries. By the end of 2002, ries have guided the effort and confirmed these achievements. he South-East Asia Region accounted for 84% of the global polio bur. Investigations into the 2002 epidemic demonstrated that a com den. Since then, however, a massive national and international response bination of low routine immunization coverage and an insufficient scale, has again brought polio to the brink of elimination in the most popu- number and quality of polio campaigns had led to a rapid accumulation lous WHO region. of susceptible children, especially in the state of Uttar Pradesh. In re- By the end of 2000, 9 of the 10 WHO Member States in the South. sponse, political oversight of the programme was markedly inceased, East Asia Region and 35 of Indias 37 states had interrupted wild polio the number of polio campaigns was raised to six per year, and addi- virus transmission as part of the global eradication effort. In addition to tional efforts were made to reach children in minority populations. Con- Bangladesh and Nepal, Myanmar has been polio-free since 2000; Bhu. sequently, by the end of September 2003, polio was at its lowest level in tan, the Democratic People's Republic of Korea, Indonesia, Maldives, Sri history(132 cases)and there was again the real possibility of forever anka and Thailand all stopped indigenous transmission prior to 1999. eliminating this devastating disease from South-East Asia by 2005

Polio Eradication: the final challenge 63 within and outside the health sector. Only the highest-level political leadership has the neces￾sary authority to ensure this accountability, particularly in the non-health ministries whose personnel and resources are so important in ensuring that all children are reached with OPV. Such high-level engagement of political leaders has brought additional, often extraordinary, benefits. Recognizing that poliovirus knew no borders, in April 1995 leaders of 18 countries of Asia, Europe and the Eastern Mediterranean began coordinating the OPV immunization of 56 million children. Similar activities followed in Africa, where the conflict-affected coun￾tries of Angola, the Democratic Republic of the Congo, Gabon, and the Republic of the Congo synchronized three rounds of NIDs from July 2001, reaching 15 million children. Through￾out the past 15 years, in countries such as Afghanistan, Angola, Sierra Leone and Sri Lanka, warring parties have laid down their weapons to participate in “days of tranquility” so that their children might be immunized against polio (7). Progress towards eradication in coun￾tries of the Eastern Mediterranean and South-East Asia Regions is detailed in Boxes 4.1 and 4.2. Finding the funds Sabin’s vision of a world without polio required reaching all children with multiple doses of OPV, which in turn required substantial financial resources and in-kind contributions from national and international sources. To mobilize and manage resources on this scale, the polio partnership established a mix of strategies and mechanisms. The success of this approach is reflected in the mobilization of more than US$ 5 billion in funding and in-kind contribu￾tions for polio eradication activities, over a 20-year period (8). While the majority of these funds went to time-limited eradication activities, a substantial proportion was directed to the strengthening of routine immunization and surveillance services. In any given country, the proportion of costs covered by national and international sources has correlated most closely with income level and health system capacity. China, for example, has estimated that over 95% of its costs were borne by the country itself. Even in the poorest countries with virtually non-existent formal health services, such as Somalia, the community absorbs 25–50% of the real costs of implementing polio NIDs through in-kind contribu￾tions. Because of the diversity of the communities, governments and partners that have Box 4.2 Responding to the challenge of polio eradication in South-East Asia In 2002, the global goal of polio eradication was jeopardized as India suffered the largest outbreak in recent history: 1600 cases were reported that year, a fivefold increase over 2001. As the epidemic spread into Indian states which had finally become polio-free in recent years, the number of infected districts more than doubled from 63 in 2001 to 159. Because of India’s long borders with Bangladesh and Nepal, the epi￾demic also threatened these polio-free countries. By the end of 2002, the South-East Asia Region accounted for 84% of the global polio bur￾den. Since then, however, a massive national and international response has again brought polio to the brink of elimination in the most popu￾lous WHO region. By the end of 2000, 9 of the 10 WHO Member States in the South￾East Asia Region and 35 of India’s 37 states had interrupted wild polio￾virus transmission as part of the global eradication effort. In addition to Bangladesh and Nepal, Myanmar has been polio-free since 2000; Bhu￾tan, the Democratic People’s Republic of Korea, Indonesia, Maldives, Sri Lanka and Thailand all stopped indigenous transmission prior to 1999. This progress is the result of a regionally coordinated, data-driven pro￾gramme that began in the early 1990s and through which National Im￾munization Days have reached over 200 million children, often synchronized across Member States and supported by regional bodies such as the South Asian Association for Regional Cooperation. Strong polio surveillance and a regional network of 17 high-quality laborato￾ries have guided the effort and confirmed these achievements. Investigations into the 2002 epidemic demonstrated that a com￾bination of low routine immunization coverage and an insufficient scale, number and quality of polio campaigns had led to a rapid accumulation of susceptible children, especially in the state of Uttar Pradesh. In re￾sponse, political oversight of the programme was markedly increased, the number of polio campaigns was raised to six per year, and addi￾tional efforts were made to reach children in minority populations. Con￾sequently, by the end of September 2003, polio was at its lowest level in history (132 cases) and there was again the real possibility of forever eliminating this devastating disease from South-East Asia by 2005

64heWorldHealthReport2003 contributed to the implementation of polio activities, it is impossible to quantify accurately the value of all financial and in-kind expenditures Of the over USS 5 billion that will have been spent on the initiative, however, a conservative estimate based on the time of volunteers and health workers during NIDs-the most labour-intensive of the strategies-suggests that polio-endemic countries will have contributed at least US$ 2.35 billion in volunteer time lone between 1988 and 2005(8). Additional public and private sector resources from the national, state, province, district and local community levels paid for petrol, social mobilize tion,training and other costs. External sources will have provided at least US$ 3 billion to help endemic countries cover polio eradication costs Of the more than 100 external donors to date, 26 will have contrib- uted more than US$ 1 million over the lifespan of the initiative and 12 at least US$ 25 million (see Figure 4.2). A particular strength of the polio initiative has been its strong partnership with a number of non-traditional donors of development aid, most notably Rotary Interna tional (see Box 4.3). The country-level budgeting and resource management processes, com- bined with centralized tracking of resource requirements and funding flows, have allowed the programme to accommodate the needs of donors and recipient countries while improv- ing the efficient use of available financing. Despite their limited infrastructure, many low- income and lower-middle-income countries have clearly demonstrated a tremendous absorptive capacity for health resources, which can rapidly achieve real health outcomes. Although the coordinated international advocacy and resource management of this initiative have been very successful, the most striking aspect of the financing for polio eradication has been the substantial contribution of endemic countries and communities themselves to en suring that their children share fully in the global vision of a world without pol Figure 4.2 Global Polio Eradication Initiative: financial support 1988-2005 ● Germany● Denmark ● Netherland ● United Kingdom Commission ●USAD ■ UN Foundation a Gates Foundation ● Canada ■ Rotary International 2003-2005 fundin Centers for disease Control and prevention US$ 210 million p

64 The World Health Report 2003 contributed to the implementation of polio activities, it is impossible to quantify accurately the value of all financial and in-kind expenditures. Of the over US$ 5 billion that will have been spent on the initiative, however, a conservative estimate based on the time of volunteers and health workers during NIDs – the most labour-intensive of the strategies – suggests that polio-endemic countries will have contributed at least US$ 2.35 billion in volunteer time alone between 1988 and 2005 (8). Additional public and private sector resources from the national, state, province, district and local community levels paid for petrol, social mobiliza￾tion, training and other costs. External sources will have provided at least US$ 3 billion to help endemic countries cover polio eradication costs. Of the more than 100 external donors to date, 26 will have contrib￾uted more than US$ 1 million over the lifespan of the initiative and 12 at least US$ 25 million (see Figure 4.2). A particular strength of the polio initiative has been its strong partnership with a number of non-traditional donors of development aid, most notably Rotary Interna￾tional (see Box 4.3). The country-level budgeting and resource management processes, com￾bined with centralized tracking of resource requirements and funding flows, have allowed the programme to accommodate the needs of donors and recipient countries while improv￾ing the efficient use of available financing. Despite their limited infrastructure, many low￾income and lower-middle-income countries have clearly demonstrated a tremendous absorptive capacity for health resources, which can rapidly achieve real health outcomes. Although the coordinated international advocacy and resource management of this initiative have been very successful, the most striking aspect of the financing for polio eradication has been the substantial contribution of endemic countries and communities themselves to en￾suring that their children share fully in the global vision of a world without polio. ● USA (CDC*) ● USAID ● Japan ● Canada Others 2003–2005 funding gap US$ 210 million ■ Rotary International ■ Gates Foundation ■ UN Foundation ▲ World Bank ▲ European Commission ● United Kingdom ● Netherlands ● Germany ● Denmark * Centers for Disease Control and Prevention. ● Public sector – 65% ■ Private sector – 25% ▲ Multilateral sector – 10% Figure 4.2 Global Polio Eradication Initiative: financial support 1988–2005

Polio Eradication: the final challenge Finding the people While strong political engagement and substantial financial and in-kind resources are essen- tial to the success of the polio initiative, they are not sufficient. These two elements have had to be complemented with sufficient people to implement the eradication strategies in every corner of the world. Although high-income and higher-middle-income countries could usu ally rely on strong health services to implement the eradication strategies, a massive gap in the critical area of human resources for health, particularly in low-income and lower-mid dle-income countries with the greatest polio burden, threatened the success of the entire global effort. The number, mix and distribution of people required to eliminate polio from countries dif- fered, depending on the strategy. The most labour-intensive strategies were the massive, time limited, supplementary immunization activities such as NIDs and"mop-up" can s The most skill-intensive strategy was that involving continuous disease surveillance and labora tory activities. In general, the very different human resource requirements of the two types of strategy were met through different approaches The number of people required to implement NIDs is tremendous. As noted above, an esti- mated 10 million volunteers and health workers immunized 575 million children during such polio eradication activities in 2001. Two key aspects of NIDs were critical to resolving the gap between existing, trained vaccinators in a country and the number needed for NIDs First, because NIDs only require administering 2 OPV drops to a child and then recording the number immunized, with 1-2 hours of training community volunteers could safely de liver the service. Second, the time-limited nature of Nids meant that volunteers were willing to participate and that other government ministries, nongovernmental organizations and private sector partners could bear the opportunity costs incurred by having their staff par ticipate. Consequently, the major challenge for national and subnational health authorities and the polio partnership became the mobilization, training, equipping and management of these human resources. Given the scale of this mass mobilization a substantial effort was made to include other interventions in nids where feasible and safe it has been estimated that the inclusion of vitamin A supplementation in polio NIDs averted 1. 25 million child hood deaths (9) The high-quality surveillance required for guiding supplementary immunization activities and monitoring their impact called for a different human resources response. Far fewer pe ple were required than for NIDs, but with a much higher level of skills to identify, notify, Box 4.3 A public-private partnership for polio eradication Rotary International is one of the four spearheading partners of the tary International has provided financial support to polio eradi- Global Polio Eradication Initiative, having endorsed the concept of a cation on an unprecedented scale. By 2005, Rotary's direct financing global effort even before the World Health Assembly resolution of 1988. will have reached over USS 500 million since 1988, 20% of the total In 1985, Rotary pledged its commitment to the international health goal external financing for the entire initiative. In addition, Rotary has been of a" polio-free world"by the time of its centenary in 2005. at the centre of the multi-agency advocacy effort that has mobilized In endemic areas, Rotarians- from more than 160 countries- USS 2.4 million in further external funding from donor governments, have volunteered their time to help ministries of health with every as. foundations, development banks and the private sector. pect of the programme, including polio vaccine delivery, health worker Rotary International has campaigned with key political leaders of transport, provision of critical equipment, and community mobilization. both endemic and polio-free countries to ensure their active participa In polio-free countries, Rotarians have continuously raised the profile tion in the programme. This regular, high-level advocacy by a private and importance of polio eradication through advocacy and public infor- sector partner has kept polio eradication high on the global agenda, mation campaigns despite many competing priorities

Polio Eradication: the final challenge 65 Finding the people While strong political engagement and substantial financial and in-kind resources are essen￾tial to the success of the polio initiative, they are not sufficient. These two elements have had to be complemented with sufficient people to implement the eradication strategies in every corner of the world. Although high-income and higher-middle-income countries could usu￾ally rely on strong health services to implement the eradication strategies, a massive gap in the critical area of human resources for health, particularly in low-income and lower-mid￾dle-income countries with the greatest polio burden, threatened the success of the entire global effort. The number, mix and distribution of people required to eliminate polio from countries dif￾fered, depending on the strategy. The most labour-intensive strategies were the massive, time￾limited, supplementary immunization activities such as NIDs and “mop-up” campaigns. The most skill-intensive strategy was that involving continuous disease surveillance and labora￾tory activities. In general, the very different human resource requirements of the two types of strategy were met through different approaches. The number of people required to implement NIDs is tremendous. As noted above, an esti￾mated 10 million volunteers and health workers immunized 575 million children during such polio eradication activities in 2001. Two key aspects of NIDs were critical to resolving the gap between existing, trained vaccinators in a country and the number needed for NIDs. First, because NIDs only require administering 2 OPV drops to a child and then recording the number immunized, with 1–2 hours of training community volunteers could safely de￾liver the service. Second, the time-limited nature of NIDs meant that volunteers were willing to participate and that other government ministries, nongovernmental organizations and private sector partners could bear the opportunity costs incurred by having their staff par￾ticipate. Consequently, the major challenge for national and subnational health authorities and the polio partnership became the mobilization, training, equipping and management of these human resources. Given the scale of this mass mobilization, a substantial effort was made to include other interventions in NIDs where feasible and safe: it has been estimated that the inclusion of vitamin A supplementation in polio NIDs averted 1.25 million child￾hood deaths (9). The high-quality surveillance required for guiding supplementary immunization activities and monitoring their impact called for a different human resources response. Far fewer peo￾ple were required than for NIDs, but with a much higher level of skills to identify, notify, Box 4.3 A public–private partnership for polio eradication Rotary International is one of the four spearheading partners of the Global Polio Eradication Initiative, having endorsed the concept of a global effort even before the World Health Assembly resolution of 1988. In 1985, Rotary pledged its commitment to the international health goal of a “polio-free world” by the time of its centenary in 2005. In endemic areas, Rotarians – from more than 160 countries – have volunteered their time to help ministries of health with every as￾pect of the programme, including polio vaccine delivery, health worker transport, provision of critical equipment, and community mobilization. In polio-free countries, Rotarians have continuously raised the profile and importance of polio eradication through advocacy and public infor￾mation campaigns. Rotary International has provided financial support to polio eradi￾cation on an unprecedented scale. By 2005, Rotary’s direct financing will have reached over US$ 500 million since 1988, 20% of the total external financing for the entire initiative. In addition, Rotary has been at the centre of the multi-agency advocacy effort that has mobilized US$ 2.4 million in further external funding from donor governments, foundations, development banks and the private sector. Rotary International has campaigned with key political leaders of both endemic and polio-free countries to ensure their active participa￾tion in the programme. This regular, high-level advocacy by a private sector partner has kept polio eradication high on the global agenda, despite many competing priorities

The World Health Report 2003 investigate and respond to cases of AFP (4). Furthermore, they had to be available on an ongoing basis. Consequently, the polio partnership focused on working with national au- thorities to expand and strengthen the existing national surveillance infrastructure wherever possible. Where this infrastructure was functionally non-existent, partners worked with na- tional authorities to establish AFP surveillance. In any particular country, the strategy pur- sued to close this human resources gap depended on the broader national strategy fo strengthening health services. In some countries, surveillance personnel received government salaries with operating costs, including vehicles and equipment, covered by international sources. In other countries, national salaries were supplemented by partners as part of a gov ernment strategy to retain highly qualified staff. In still others, WHO and governments es tablished and operated a joint surveillance programme. In addition, WHO hired and deployed nearly 1500 national and international staff to provide technical assistance and even conduct surveillance activities in those areas with the weakest capacity. Through this mix of strategies and approaches to the gap in human resources for health, it has been possible to reach almost every child in the world with OPV and other interventions (such as Vitamin A supplementation), irrespective of socioeconomic status, religion, minor- ty status, geography or even war. In addition, a truly global surveillance and laboratory ca- pacity now exists to identify and respond rapidly to polio, as well as to many other diseases of public health importance such as measles, neonatal tetanus, meningitis, cholera and yellow fever, depending on the country(10). In the Western Pacific Region, this capacity contrib- uted to the international response to the SARS outbreaks of 2002-2003 Prospects for a polio-free future As the result of an aggressive, deliberate and internationally coordinated effort, polio has changed from being a devastating disease with a global distribution to one that is now geo- graphically restricted to seven countries. To capitalize on this progress, substantial effort is now required to interrupt the final chains of polio transmission, certify that achievement, and minimize the risk of polio being reintroduced in the future. The polio partner ship's Polio Eradication Strategic Plan 2004-2008 summarizes these challenges in its major objectives. First, the final chains of poliovirus transmission must be interrupted in the remaining seven countries. Particular effort will be required in India, Nigeria and Pakistan, which now ac count for 99% of the worlds polio burden and remain a source of importation to polio-free areas. Within these countries, five of the 76 states or provinces are the key to global eradica tion; with sustained high-level political engagement, oversight and accountability in each one, high-quality NIDs could rapidly reach all children and halt polio transmission within 12 months Second, the global interruption of wild poliovirus transmission must be verified by the glo- bal Commission for the Certification of Poliomyelitis Eradication. Certification requires that all countries provide documentation demonstrating the absence of wild poliovirus circula tion for at least three years, in the presence of high-quality surveillance, as well as the"con- tainment "of all stocks of wild poliovirus Containment requires that within one year of the interruption of wild poliovirus transmission globally, countries will have identified all stocks of wild poliovirus and ensured their storage and handling under appropriate biosafety con ditions(see Figure 4.3)

66 The World Health Report 2003 investigate and respond to cases of AFP (4). Furthermore, they had to be available on an ongoing basis. Consequently, the polio partnership focused on working with national au￾thorities to expand and strengthen the existing national surveillance infrastructure wherever possible. Where this infrastructure was functionally non-existent, partners worked with na￾tional authorities to establish AFP surveillance. In any particular country, the strategy pur￾sued to close this human resources gap depended on the broader national strategy for strengthening health services. In some countries, surveillance personnel received government salaries with operating costs, including vehicles and equipment, covered by international sources. In other countries, national salaries were supplemented by partners as part of a gov￾ernment strategy to retain highly qualified staff. In still others, WHO and governments es￾tablished and operated a joint surveillance programme. In addition, WHO hired and deployed nearly 1500 national and international staff to provide technical assistance and even conduct surveillance activities in those areas with the weakest capacity. Through this mix of strategies and approaches to the gap in human resources for health, it has been possible to reach almost every child in the world with OPV and other interventions (such as Vitamin A supplementation), irrespective of socioeconomic status, religion, minor￾ity status, geography or even war. In addition, a truly global surveillance and laboratory ca￾pacity now exists to identify and respond rapidly to polio, as well as to many other diseases of public health importance such as measles, neonatal tetanus, meningitis, cholera and yellow fever, depending on the country (10). In the Western Pacific Region, this capacity contrib￾uted to the international response to the SARS outbreaks of 2002–2003. Prospects for a polio-free future As the result of an aggressive, deliberate and internationally coordinated effort, polio has changed from being a devastating disease with a global distribution to one that is now geo￾graphically restricted to seven countries. To capitalize on this progress, substantial effort is now required to interrupt the final chains of polio transmission, certify that achievement, and minimize the risk of polio being reintroduced in the future. The polio partner￾ship’s Polio Eradication Strategic Plan 2004–2008 summarizes these challenges in its major objectives. First, the final chains of poliovirus transmission must be interrupted in the remaining seven countries. Particular effort will be required in India, Nigeria and Pakistan, which now ac￾count for 99% of the world’s polio burden and remain a source of importation to polio-free areas. Within these countries, five of the 76 states or provinces are the key to global eradica￾tion; with sustained high-level political engagement, oversight and accountability in each one, high-quality NIDs could rapidly reach all children and halt polio transmission within 12 months. Second, the global interruption of wild poliovirus transmission must be verified by the Glo￾bal Commission for the Certification of Poliomyelitis Eradication. Certification requires that all countries provide documentation demonstrating the absence of wild poliovirus circula￾tion for at least three years, in the presence of high-quality surveillance, as well as the “con￾tainment” of all stocks of wild poliovirus. Containment requires that within one year of the interruption of wild poliovirus transmission globally, countries will have identified all stocks of wild poliovirus and ensured their storage and handling under appropriate biosafety con￾ditions (see Figure 4.3)

Polio Eradication: the final challenge Third, appropriate policies will need to be developed, and internationally agreed, for the duction of wild poliovirus and ensure the global capacity to manage such an event shoulde post-certification era. These policies must be designed to both minimize the risk of reint occur. Consequently, policies will be needed in four areas: polio detection and notification, long-term biocontainment of all poliovirus strains( that is, wild and vaccine strains), polio vaccine stockpiles, and routine immunization(11). The development of these policies will be even more complex than it was for smallpox, for a number of reasons. For example, the very low risk of vaccine-derived polioviruses regaining the capacity to cause outbreaks is now well documented. Furthermore, the risks of international terrorism have substantially affected the willingness of some policy-makers to plan for the discontinuation of routine polio im munization in the near future, regardless of the economic benefits. Because of the complex ity of these issues, ongoing research in this area will be complemented by broad consultation with governments and stakeholders through the World Health Assembly and other forums from 2004 onwards(11). Scaling up the delivery of health services The greatest success of the polio eradication initiative to date has been its capacity to reach virtually every population in the world with a basic health service, regardless of geography, religion, conflict or even the strength of the health system. This experience in scaling up to plement fully the eradication strategies is now one of the most valuable assets of the pro gramme. Perhaps the most frequent, if unfair, criticism of the highly regarded smallpox eradi- cation effort was that it left little infrastructure behind to tackle other diseases. Indeed the ultimate legacy of the polio eradication initiative will depend largely on the extent to which the experience and lessons learnt are used in scaling up the delivery of other health services Figure 4.3 Global action plan for laboratory containment of wild polioviruses, February 2003 8 urveys not started Surveys completed, inventories submitted

Polio Eradication: the final challenge 67 Third, appropriate policies will need to be developed, and internationally agreed, for the post-certification era. These policies must be designed to both minimize the risk of reintro￾duction of wild poliovirus and ensure the global capacity to manage such an event should it occur. Consequently, policies will be needed in four areas: polio detection and notification, long-term biocontainment of all poliovirus strains (that is, wild and vaccine strains), polio vaccine stockpiles, and routine immunization (11). The development of these policies will be even more complex than it was for smallpox, for a number of reasons. For example, the very low risk of vaccine-derived polioviruses regaining the capacity to cause outbreaks is now well documented. Furthermore, the risks of international terrorism have substantially affected the willingness of some policy-makers to plan for the discontinuation of routine polio im￾munization in the near future, regardless of the economic benefits. Because of the complex￾ity of these issues, ongoing research in this area will be complemented by broad consultation with governments and stakeholders through the World Health Assembly and other forums from 2004 onwards (11). Scaling up the delivery of health services The greatest success of the polio eradication initiative to date has been its capacity to reach virtually every population in the world with a basic health service, regardless of geography, religion, conflict or even the strength of the health system. This experience in scaling up to implement fully the eradication strategies is now one of the most valuable assets of the pro￾gramme. Perhaps the most frequent, if unfair, criticism of the highly regarded smallpox eradi￾cation effort was that it left little infrastructure behind to tackle other diseases. Indeed, the ultimate legacy of the polio eradication initiative will depend largely on the extent to which the experience and lessons learnt are used in scaling up the delivery of other health services. Surveys not started Surveys under way Surveys completed, inventories submitted Figure 4.3 Global action plan for laboratory containment of wild polioviruses, February 2003