Poliomyelitis: polio transition planning and polio post-certification: report by the Director-General

EXECUTIVE BOARD EB148/23 148th session 16 December 2020 Provisional agenda item 15.2 Poliomyelitis Polio transition planning and polio post-certification Report by the Director-General 1. This report provides an update on the implementation of the Strategic Action Plan on Polio Transition (2018–2023), with a particular emphasis on the impact of the COVID-19 pandemic on key activities and the mitigation measures that have been taken by the Secretariat. 2. The Strategic Action Plan, which was requested by the Seventieth World Health Assembly in decision WHA70(9) (2017) and noted by the Seventy-first World Health Assembly,1 has three key objectives: • to sustain a polio-free world after eradication of polio virus; • to strengthen immunization systems, including surveillance for vaccine-preventable diseases, in order to achieve the goals of WHO’s Global vaccine action plan 2011–2020; • to strengthen emergency preparedness, detection and response capacity in countries to fully implement the International Health Regulations (2005). 3. The Secretariat has been working with the national authorities of the 16 priority countries.2 Additionally, the Regional Office for the Eastern Mediterranean is working with four additional countries that it has prioritized owing to their fragility and high-risk status3 to develop and implement their national plans for polio transition. Many of these countries depend heavily on the infrastructure established through the Global Polio Eradication Initiative. To maintain or selectively re-purpose polio assets, to sustain eradication, to avoid backsliding on vaccine-preventable disease control and elimination efforts, and to strengthen emergency preparedness, detection and response capacities all need careful planning. 1 See document A71/9 and the summary records of the Seventy-first World Health Assembly, Committee A, sixth and eighth meetings (see https://apps.who.int/iris/handle/10665/325993). 2 The 16 global polio transition priority countries by region are: African Region – Angola, Cameroon, Chad, Democratic Republic of the Congo, Ethiopia, Nigeria and South Sudan; South-East Asia Region – Bangladesh, India, Indonesia, Myanmar and Nepal; and Eastern Mediterranean Region – Afghanistan, Pakistan, Somalia and Sudan. 3 Iraq, Libya, Syrian Arab Republic and Yemen. EB148/23 2 COVID-19: A CHALLENGE AND AN OPPORTUNITY FOR POLIO TRANSITION 4. The COVID-19 pandemic has led to the suspension or slowing down of many polio and immunization activities at the country level, including the planned cross-WHO country missions to review transition implementation. Despite the consequent challenges, progress has been made towards the objectives of the strategic action plan on polio transition. 5. Since the early days of the pandemic, high-level oversight of polio transition within the Secretariat has remained active. The Steering Committee on Polio Transition continues to meet regularly, with a focus on monitoring the impact of the COVID-19 crisis, adopting mitigation measures and assessing opportunities for integration presented by the pandemic response. 6. Polio transition activities are managed in a more integrated manner than previously with the participation of all programmes and better aligned with programmatic and regional priorities, capitalizing on the technical and programmatic capacities throughout the Organization. To assist this pivot towards more integrated planning and action, a technical working group has been put in place across WHO headquarters and the regional offices. The working group meets every two weeks to track progress and agree on priorities. It acts as a platform for collective decision-making and transparent information-sharing. In addition, programmatic linkages have been established with the special programme on primary health care, as the capacity that exists through the polio network can support the strengthening of primary health care in priority countries. 7. The COVID-19 pandemic is an unprecedented challenge for the world, but it also presents a unique opportunity for the systematic and careful transition of polio assets and functions. COVID-19 has demonstrated once again that polio staff constitute an essential public health workforce that can be quickly mobilized to support Member States. In addition, the response to COVID-19 is accelerating cross-programmatic integration, driving programmes to plan and work together in a more integrated manner. The role of the polio network for the response to COVID-19 and opportunities for the future 8. Within weeks of the reporting of the new disease, polio assets in WHO’s African, South-East Asia and Eastern Mediterranean regions – the three regions prioritized for polio transition – were able to pivot quickly to provide support to countries in preparing for and responding to the crisis. 9. Polio networks have several unique advantages that make them particularly useful for responding to this new crisis. First, they were already in place and could start working immediately, a key attribute given the speed with which the SARS-CoV-2 virus circled the globe. Secondly, given their experience with outbreaks and other health emergencies, polio teams had the knowledge and expertise needed to respond to a new emergency. Thirdly, thanks to their long-standing relationships in countries, they quickly became trusted members of the countries’ public health teams. 10. The contributions of the polio teams to the COVID-19 response in the polio-transition priority countries in the three regions have been comprehensively documented.1 Real-time data collected in the 1 https://apps.who.int/iris/bitstream/handle/10665/336261/9789240011533-eng.pdf?sequence=1&isAllowed=y (accessed 7 December 2020). EB148/23 3 Africa Region1 show that in 36 countries 2080 polio-funded personnel have participated in the response, with most personnel spending more than 50% of their time on activities related to COVID-19. In the South-East Asia Region, almost 2600 personnel spent between one quarter and three quarters of their time on COVID-19 response, and in countries of the Eastern Mediterranean Region in total 1243 polio staff contributed to the pandemic response efforts. In all the regions, most of the teams are located at the district and community levels. 11. Beyond their contributions to the response to the pandemic, polio networks have a vital role to play in the recovery phase. They are already providing vital support to reach children who have missed vaccinations because of service disruptions related to COVID-19. The polio network is also well positioned to play a role in assuring the equitable distribution of COVID-19 countermeasures, including delivery of new vaccines. Therefore, the current pandemic presents an opportunity for polio transition, especially if the investments for COVID-19 could be leveraged to build sustainable capacities that would lead to longer-term preparedness and resilient health systems. Integration: the pathway towards successful transition 12. The objective of polio transition is to mainstream the functions supported through the Global Polio Eradication Initiative into national health systems. Until then, WHO has to maintain its capability to support these essential functions, while helping to build country capacity. The scope and duration of WHO’s support will depend on the country context. In fragile and conflict-affected countries, WHO’s support will need to continue in the longer term. 13. COVID-19 has underscored the need for the Secretariat to provide support to countries in a more comprehensive manner, accelerating the momentum for cross-programmatic integration. In the African, South-East Asia and Eastern Mediterranean regions, this programmatic integration, using polio surveillance and immunization staff to support the responses to COVID-19, is building upon the polio network as activities resume such as case identification, contract tracing and risk communication in addition to their ongoing polio and immunization work. 14. To capitalize on this growing momentum within the context of COVID-19, “integrated public health teams” are being set up in WHO country offices in polio transition priority countries, bringing together the polio, emergencies and immunization expertise and building on the strong polio footprint. The integrated public health teams have country-specific expanded terms of reference. They will be operationalized in a phased manner over the course of 2020–2021, aligned with the country context and operational needs. The first phase focuses on activities immediately related to the response to COVID-19, such as outbreak investigation and contact tracing, and in the second activities will centre on recovery and resilience. Lessons learned from the initial examples will inform further implementation. 15. COVID-19 is also accelerating integration of the polio and immunization programmes in countries prioritized for polio transition. Disruptions to immunization services caused by the pandemic have highlighted the urgent need for more coordinated and integrated approaches between polio and immunization stakeholders. Through a multi-partner effort led by WHO, an “interim Programme of Work for Integrated Actions” is being developed which outlines the key activities and strategies required to meet the unprecedented COVID-19-related challenges. Other related developments on the 1 WHO Regional Office for Africa. Contribution of polio resources to COVID-19 response [website] (https://rebrand.ly/polio2covid, accessed 26 October 2020). EB148/23 4 immunization front are the finalization of both the Immunization Agenda 20301 and the global strategy on comprehensive vaccine-preventable disease surveillance.2 The former places “sustainable transitions” at its forefront. The latter aims to mitigate the risk that the decline in polio funding will undermine surveillance activities, by guiding countries to put in place sustainable surveillance systems for a comprehensive set of priority vaccine-preventable diseases and to integrate surveillance functions with those for other across vaccine-preventable diseases and, where possible, other diseases. Together with partners, the Secretariat is currently working on costing the external funding requirements for the implementation of comprehensive vaccine-preventable disease surveillance in low-income countries. COUNTRY-LEVEL PROGRESS 16. COVID-19 has slowed down country-level activities, including the suspension of planned country missions. It also has implications for the overall financial landscape. As countries face severe economic shocks to respond to this new and unprecedented crisis, providing sustainable funding for polio assets becomes challenging. This has an impact on the planned implementation timelines for the polio transition activities. Despite these difficulties, progress has been made in 2020, in all the three regions. African Region 17. The Regional Office for Africa conducted a real-time survey to document the contributions of polio staff to COVID-19 preparedness and response. The findings show that in 36 countries the polio network provided crucial support, especially at the subnational level, as countries built up systems to contain COVID-19. These results prove the potential of this network in the current context and for the future. 18. Despite the suspension of planned country visits, the Secretariat held monthly virtual meetings with focal points in the seven priority countries to follow up on progress and offer support. In Angola, the implementation of the polio transition plan has started under the leadership of the Government, with support from the World Bank and Gavi, the Vaccine Alliance. Nigeria has updated its business case, which provides the basis of its national transition plan. In the remaining priority countries an implementation road map is being developed in order to lay out country-specific action plans that are realistic, time-bound and achievable. 19. Implementation of national transition plans is a standing item on the agenda of the Regional Committee for Africa. The report submitted to the Regional Committee at its seventieth session outlined the progress achieved, gaps and challenges, and, to address those challenges, proposed six specific actions for Member States and national stakeholders and three for WHO.3 1 WHO. Immunization Agenda 2030: a global strategy to leave no one behind, Draft Four – 2 April 2020 (https://www.who.int/immunization/immunization_agenda_2030/en/, accessed 27 October 2020). 2 WHO. Global strategy on comprehensive vaccine-preventable disease surveillance [website] (https://www.who.int/immunization/monitoring_surveillance/burden/vpd/BLS20116_IA_Global_strategy.pdf?ua=1, accessed 27 October 2020). 3 WHO Regional Office for Africa. Ensuring implementation of national polio transition plans in the African Region. Seventieth session of the Regional Committee for Africa, Document AFR/RC70/8. Brazzaville: World Health Organization Regional Office for Africa; 2020 (https://www.afro.who.int/sites/default/files/2020-07/AFR-RC70- 8%20Ensuring%20implementation%20of%20national%20polio%20transition%20plans%20in%20the%20African%20Regio n.pdf, accessed 27 October 2020). EB148/23 5 South-East Asia Region 20. The South-East Asia Region is the most advanced in terms of progress on polio transition. Despite the challenges imposed by COVID-19, implementation of the national polio transition plans continued and crucial activities are on track. 21. Polio transition is an integral part of the polio progress report submitted to the Regional Committee for South-East Asia at its seventy-third session, which called upon Member States for continued commitment in implementing their transition plans, emphasizing the need to mobilize domestic resources or alternative sources of funding for long-term sustainability.1 Similarly, the WHO South-East Asia Immunization Technical Advisory Group recommended all five priority countries to operationalize their national polio transition plans and to mitigate any adverse impact of COVID-19 on polio transition, asking national immunization technical advisory groups to provide a progress report on implementation by the end of 2020.2 22. A milestone in the Region was the mid-term assessment of the transition of WHO India National Polio Surveillance Project (NPSP) from polio to public health. The mid-term assessment contains both programmatic and non-programmatic components, including human resources, operations and finance, highlighting that its transition has contributed significantly to strengthening the public health system in India. A significant portion of the cost was provided by the national Government within the 2018–2020 time frame. In line with the key recommendations, the Ministry of Health and Family Welfare and WHO will jointly develop a road map to monitor progress at three levels (national, state and district). 23. Because of COVID-19 travel restrictions, the planned regional workshop to assess progress and develop a road map for longer-term sustainability will be held virtually with each individual country before the end of 2020. 24. WHO’s surveillance networks in all priority countries of the South-East Asia Region have provided substantive support to the response to COVID-19. The Regional Office is documenting these contributions to demonstrate the strengths of the networks, show how lessons learned from polio were applied to COVID-19, and to evaluate the way forward. Eastern Mediterranean Region 25. Although making up only 9% of the global population, the Eastern Mediterranean Region contains 43% of those people who rely on immediate and ongoing humanitarian assistance,3 thereby constituting a specific context for polio transition. Health systems that have been disrupted by political instability and conflict coupled with various health emergencies affecting the Region seriously impede 1 WHO Regional Office for South-East Asia. Progress reports on selected Regional Committee resolutions, section 9. Seventy-third session of the Regional Committee for South-East Asia. World Health Organization Regional Office for South-East Asia; 2020 (https://apps.who.int/iris/bitstream/handle/10665/333613/sea-rc73-9.pdf?sequence=1&isAllowed=y and https://apps.who.int/iris/bitstream/handle/10665/333613/sea-rc73-9Add1.pdf?sequence=2&isAllowed=y, accessed 29 October 2020). 2 WHO Regional Office for South-East Asia. Eleventh annual meeting of the WHO South-East Asia Regional Immunization Technical Advisory Group (July 2020). New Delhi: World Health Organization Regional Office for South-East Asia; 2020 (https://apps.who.int/iris/handle/10665/335831, accessed 29 October 2020). 3 OCHA. Global humanitarian overview 2020. United Nations Office for the Coordination of Humanitarian Affairs; New York: 2019 (https://www.unocha.org/sites/unocha/files/GHO-2020_v9.1.pdf, accessed 29 October 2020). EB148/23 6 the implementation of polio transition plans. Therefore, countries in the Region that host large polio networks will require longer-term support from the Secretariat. 26. The process for transition planning and implementation in the Region is overseen at the highest level, through the regional Steering Committee on Polio Transition, chaired by the Regional Director for the Eastern Mediterranean. Two country missions were conducted to Iraq and Sudan before the travel restrictions imposed because of COVID-19. These visits were followed up with high-level advocacy to implement the national transition plans, emphasizing the contributions of the polio networks to the COVID-19 response. Consequently, in Iraq, field surveillance functions of the polio programme were transferred from WHO to the national health programme. In Sudan, implementation was delayed owing to the impact of COVID-19, coupled with an outbreak of disease due to circulating vaccine-derived poliovirus type 2. In Yemen, polio staff who were previously funded by the Global Polio Eradication Initiative are now being supported through WHO’s immunization and emergencies programmes. The progress report submitted to the Regional Committee for the Eastern Mediterranean at its sixty-seventh session included an update on the implementation of polio transition activities and specific recommendations.1 27. Given that the presence in the Region continues of the two remaining polio-endemic countries and conflict-affected countries that require sustained support from the Secretariat, cross-programmatic integration, especially among the polio, immunization and emergencies programmes, is essential for a successful polio transition. Therefore, the Regional Office for the Eastern Mediterranean is, as a priority, implementing the integration of public health teams in four countries (Afghanistan, Pakistan, Somalia and Sudan) as a bridging strategy until functions are transferred to the national governments. BURGET, PLANNING AND HUMAN RESOURCES Planning for WHO’s programme budget 2022–2023 28. The Strategic Action Plan on Polio Transition (2019–2023) included an estimation of the costs of essential public health functions to be mainstreamed and/or integrated into national health structures and WHO’s programmes. The estimated costs of these functions for the period of WHO’s Thirteenth General Programme of Work (2019–2023) have been calculated to be US$ 667 million. These estimated costs have been included in the base segment of WHO’s programme budget. 29. As an integral part of planning for the proposed programme budget 2022–2023, the Secretariat has initiated a process to distinguish the costs of polio eradication from the essential functions that will need support from WHO, in line with the three key objectives of the Strategic Action Plan. These essential functions will be mapped and costed against their appropriate programmatic outputs and outcomes and will be included in the base segment of the proposed programme budget 2022–2023 under relevant programmatic outcomes. 1 WHO Regional Office for the Eastern Mediterranean. Progress report on polio eradication. Sixty-seventh session of the Regional Committee for the Eastern Mediterranean, document EM/RC67/INF.DOC.1. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2020 (https://applications.emro.who.int/docs/EMRC67INFDOC1-eng.pdf, accessed 27 October 2020). EB148/23 7 Update on human resources 30. The Secretariat continues to monitor the polio programme staffing through a dedicated database of polio human resources that has been developed for this purpose. Table 1 details the decline in the number of filled positions by 22% since 2016.1 Table 1. Number of polio staff positions supported by the Global Polio Eradication Initiative, by major office (2016–2020) MONITORING AND EVALUATION OF POLIO TRANSITION Monitoring and evaluation framework 31. The monitoring and evaluation framework continues to be an important component of the Strategic Action Plan on Polio Transition. It aims to facilitate effective monitoring of progress in priority countries. 32. A dashboard to monitor progress on polio transition based on the monitoring and evaluation framework of the Strategic Action Plan has been developed and published on the WHO website.2 It aims to ensure a transparent and regular way to monitor progress towards the three key objectives of the Strategic Action Plan. It provides a set of output and process indicators for the priority countries. Data for 2018 and 2019 have been already uploaded, and the dashboard will be updated twice a year, under the oversight of the Steering Committee on Polio Transition. 1 For more detailed information refer to WHO website:(https://www.who.int/teams/polio-transition-programme/HR- planning-and-management, accessed 29 October 2020). Annex 1 –WHO staff members funded by the Global Polio Eradication Initiative aggregated by contract type; Annex 2 – WHO staff members funded by the Global Polio Eradication Initiative aggregated in major offices, aggregated by grade and contract type. 2 WHO. Polio transition programme: monitoring and evaluation dashboard [website] (https://www.who.int/teams/polio-transition-programme/polio-transition-dashboard, accessed 29 October 2020). Major office 2016 2017 2018 2019 2020 Variation between 2016 and 2020 Headquarters 77 76 70 72 71 -8% Regional Office for Africa 826 799 713 663 594 -28% Regional Office for South-East Asia 39 39 39 36 36 -8% Regional Office for Europe 9 8 4 5 4 -56% Regional Office for the Eastern Mediterranean 155 152 153 170 146 -6% Regional Office for the Western Pacific 6 6 5 3 3 -50% Total 1 112 1 080 984 949 867 -22% Source: Global Polio Eradication Initiative. EB148/23 8 33. Data from the first year of monitoring (before COVID-19) show an increase in both coverage with inactivated polio vaccine as well as the second dose of measles vaccine in priority countries and surveillance for acute flaccid paralysis. In two of the three WHO regions concerned with polio transition, the core capacities for emergency preparedness, detection and response under the International Health Regulations (2005) have increased. The dashboard will allow regular monitoring of the impact of polio transition. Polio Transition Independent Monitoring Board 34. The Polio Transition Independent Monitoring Board has been reconstituted, with new membership and terms of reference. Owing to the COVID-19 pandemic, the first meeting of the Board had been postponed to 3–5 November 2020. The work of the Polio Transition Independent Monitoring Board will be closely aligned with that of the Independent Monitoring Board of the Global Polio Eradication Initiative. ACTION BY THE EXECUTIVE BOARD 35. The Board is invited to note the report and to focus its deliberations on the best way to support the implementation of polio transition activities within the context of COVID-19. = = =