The euphoria in the Polio programme turned out to be pretty ephemeral with the resurgence of Polio cases in North Waziristan, which now stands at 12 from the same district in Khyber Pakhtunkhwa province, against one case in Afghanistan, the only second endemic country. The resurgence of cases in Malawi, Mozambique, the UK and now the US, which has been declared polio-free a decade ago, should raise alarm bells in the global polio eradication teams’ cosy rooms. A Polio case anywhere is a case everywhere, the virus doesn’t respect borders.

It is still a perplexing conundrum how countries like Somalia, South Sudan, Sierra Leone, DRC etc. with poorer health indicators, and dysfunctional health and governance systems could eradicate Polio but Pakistan despite being well ahead in all domains, is still struggling? Something is surely not working? The programme’s simplistic view is when children are missed for any reason the virus circulation is established and cases are all but a natural outcome. One can engineer any logic, any self-assurance but the case surge’s mirror shows serious flaws in the big scheme of things.

Of the many, the key reason that has surfaced – of very late though- is the hidden refusals i.e. when the teams- for lack of motivation- and the community – for lack of conviction- collude on finger marking the children but not vaccinating; this is the programme faux paux. This scribe has pushed limits to advocate for curbing this but the programme then in self-proclaimed confidence turned a deaf ear to the advice. Despite the tantrum of the “New Communication strategy” there is visible unchartered territory that the programme needs to navigate.

The community refusal in a way itself is a manifestation of an existing deep-seated strategic and programmatic gap. Worrying is the absence of a realisation in the high offices that Polio is rather intertwined in social, anthropological, cultural and humanitarian fabrics. The real problem is not small hiccups on the ground but the absence of vision and strategic depth at the higher level, unfortunately, this is for reasons put under the carpet. The programme management structure doesn’t seem to fit this multi-stakeholder and multi-million dollar programme. The structure remained an “inverted pyramid”, a top-heavy one, in terms of decisions making and incentives, contrary to the need of the programme of this scale. A just and equitable accountability system is largely missing from the programme architecture, only the poor lot face the music.

The private sector which could plug some vital gaps hasn’t been adequately tapped. The absence of a strategic balance between the leadership, management and technical domains is doomed to keep us on our toes. The programme risk analysis system seems to have missed some existing “blind spots” the situation now has proved this right. Routine Immunisation has remained stagnant in high-risk areas like North Waziristan and Southern KP. Despite some serious efforts, there is still a disproportion between Ops and Comms components.

The contextualisation and specialisation required to win the minds and hearts are found missing. Demand-based refusals keep erupting and organised community boycotts are used as a bargaining chip but the programme is visibly devoid of a long-term strategic solution. “One size fits all strategies” and stereotyping raise questions on programme lesson learning capacity. The environment for the FLWs (Front Level Workers) for various reasons is no doubt harsh and unconducive. The lack of injecting ample motivation into the FLWs has been off the programme radar. This is by far the bigger reason for failure than trivialities.

In the back backdrop of all this, there is a dire need for “a programme rethink” that can ensure leading and managing the programme successfully even if out of the comfort zone of “the Lords of polio” In the 1st place, the government should create a broad-based forum of “Neutral experts” from Public health, the development sector, media and academia to work as a “Strategic advisory Committee”. This forum would develop a “National Polio Narrative” so the big scheme of things can be modified. A national round table on Polio Eradication- participated by all mainstream political parties- could be another right step forward. To engage and buy sustained “good Will” of Media and social media, the media house owners, editors, and top anchors are effectively engaged in selling the “Neo-Polio model”. The provincial EOCs, hitherto, disempowered, are empowered to the extent to decide the operational routine issues at the minimum. It is imperative to establish “provincial hubs for Innovation and research” in each province. Integrating Routine Immunisation in all phases of the programme cycle and creating a meaningful synergy between the two could prove a win-win. For enhancing FLW’s motivation, performance-based recognition and career pathways are designed so this cadre is optimally utilised in Polio and beyond.

The booming private sector is strategically engaged in areas of research, advocacy, demand creation and independent monitoring. The new programme focus should shift to cost-effectiveness, quality and impact rather than the processes, quantity, and business as usual. Generating a fine balance between quantity and quality, the campaign spree should be minimised to 3 to 5 rounds per annum, supplemented by an IPV, and OPV vaccination rounds as needed. The new nOPV vaccine is a more stable vaccine and the programme should use this in outbreak zones of cVDPV2, as available. To attain wider community acceptability, the pilot integrated health services package should be extended to medium-risk UCs and other areas of high importance. At the UC level an inclusive “refusal conversion Committee” be established and incentivised to bring sustainable dividends. “Brand ambassadors” for each locality should be identified and deployed into high-risk groups. Optimum utilisation of local religious groups is expected to boost public confidence. More neutral avenues like the “Pakistan Pediatrics association”, “National Ulema and Mashaikh Council”, Local community committees, and trade unions are engaged to amplify the programme’s voice. It’s pivotal that all communication interventions are risk steered and guided by a “challenge mapping” exercise that can fine-tune the granular specifics. Creating a pragmatic balance between the technical and human factors is the best way forward; in innovation and “out of the comfort zone actions” lies the glory.