By Shahela Sajanlal
The most recent election that took place in India earlier this year was termed to be one of the most complex management exercises. It cost the country over $ 600 million, was carried out in 9 phases, over 45 days, in over 500 constituencies, where 800 million people were eligible to vote, with over 900,000 polling stations using over 1 million electronic. A mammoth production the country was able to pull off successfully. In spite of the lack of infrastructure, resources and awareness, I believe there has to be something the world can learn.
In comparison to an election, running a focused polio eradication program with a much smaller population seems much easier, but take a look at these numbers from a program implemented in the 1980’s in India – An estimated cost of $ 30 million, 125 million children under the age of 5, 300 million doses of OPV (needed to be kept in a cool place), now does not seem simple either, but it worked even though it was a long time ago. The graph below shows the remarkable progress of polio eradication in the country since 1980.
In spite of poor health infrastructure, over populated cities, a big population living below the poverty line, it seemed like something was going well. The model adopted for the program was simple and focused. Today this model is being referred to and replicated in similar situations where programs need to be run at scale. The goal and strategy for the program was straightforward:
– Immunize every child below the age of 1 with at least 3 doses of OPV (orally administered polio vaccine )
– Run National Immunization Days and House to House Campaigns that would serve as a vehicle to pursue the consistent effort
– Surveillance of AFP (Acute Flaccid Paralysis) to identify reservoirs of where the disease persisted
I could talk about the plans, the logistics, the resources used and the challenges faced, but I would like to offer something simpler. The model proved that simplicity, thoughtfulness and persistence can achieve large scale and sustainable impact. Some of the most important elements of the program that can be associated with its success were:
– Meeting people where they were: The campaign used local religious leaders and community milk sellers to influence people. The state of Uttar Pradesh, where the program was implemented successfully, is one of the poorest states in the country, with a high rate of labour movement. Campaign workers would target families at the train and bus stations, when they were moving to find work or at religious places where people spent a lot of their time. Even though the campaign had specified days where people would come to the booths, they had simplified their distribution model to a large extent and were going where people were.
– Coordinated effort through a strong workforce: The Government of India along with WHO set up NPSP – National Polio Surveillance Project also joined by Dr Banerjee who was involved in the fight against polio initially. Given their strategy the program’s biggest asset was their workforce. They provided government employees time to work with NPSP, the CDC also provided employees and shared costs to run the program. Funding initially came from Rotary International, a non profit organization with members from middle class and upper middle class families. The WHO and UNICEF provided program support, technical expertise, strategic planning and logistical expertise for implementation of the program. It was not only about the big names being involved, but was also about people on the ground who ran the program.
– Simple Solutions: A black mark on the child’s finger to indicate that she had been immunized helped in more accurate data collection. At that point the campaign may not have had a more efficient way of marking a child or a house that they had immunized, but this was simple and effective way to tell. Today, if we were to come up with a method to track data from a program, we wouldn’t look beyond technology, which isn’t always the best option.
Having offered this angle to one of the most successfully run global health programs, I do not intend to undermine in any way the amount of expertise – both technical, program related and medical that would have gone into this effort. It was a well structured and organized effort, detailed logistical plans in the hands of field workers that helped the program. It is creditable what the program was able to achieve. In each national polio campaign, 2.3 million lakh vaccinators, led by 155,000 supervisors, visit 209 million households to immunize 170 million children up to the age of 5 years.
According to BBC’s article, Rukshar Khatoon is India’s last polio patient.
We realize soon enough that everything going forward does not have to be about BIG data, connecting the world, scalable technologies – though each of these have a big impact on health and on the world, some things are still about using simple and straightforward methodologies.