WASHINGTON, June 28, 2010—Between 2003 and 2007, Nigeria registered an average of 1,000 cases of polio each year. But just three cases of the dreaded disease have been registered in the country so far in 2010.
This sharp decline is extremely significant because communities were reluctant to have the polio vaccine given to children in Nigeria just a few years ago. Clearly, something has changed.
“I would attribute this dramatic turnaround largely to the fact that a strong attempt was made to engage traditional leaders in northern Nigeria,” said Dinesh Nair, Senior Health Specialist at the World Bank. “There were widespread misconceptions about the vaccine, including that it would affect fertility, but there is far more trust today than there was even a year ago.”
Although three reported cases could mean that infection is still widely prevalent, Nair said the turnaround has been phenomenal. And Nigeria’s Primary Health Care Development Agency (NPHCDA) emphasized in a 2010 report that working with sociopolitical structures on the ground was key to success.
A golden opportunity
A meeting of all traditional rulers of Northern Nigeria—which has been the epicenter of the polio epidemic in the country—provided a golden opportunity a year ago, in June 2009, to forge a clear path forward. The gathered leaders endorsed the creation of a task team, including one of their own representatives, which would both brief them and be accountable to them.
“We commit the traditional institutions in Northern Nigeria to avail all at their disposal including the detailed knowledge and access to community to help in the successful implementation of Immunization Activities and also in resolving other community health concerns,” the leaders said in their communiqué issued after the meeting.
Soon afterward, the leaders sensitized their entire structure down to the settlement level on all aspects of the Polio Eradication Initiative. Activities that began through this existing hierarchy included mass mobilization, community education and monitoring of activities.
“A good understanding of how the system is organized is absolutely essential,” notes Dr. M.Z. Mahmud, author of the NPHCDA report. “This cannot be donor driven, but must be purely homegrown. We have to work through channels that already exist.”
Results in less than a year
In a very short span of time, there were major observable differences in results. Even though these results are still provisional and incomplete, they are extremely significant. As the graph below shows, the polio burden fell by 92 percent between the first and second halves of 2009, from 360 confirmed cases between January and June to 28 cases between July and December.
Trend of polio burden comparing 1st and 2nd halves of the year
“Traditional leaders became involved at the beginning of the second period, during which we had exactly the same number of Intensive Polio Days as in the first period,” Mahmud said. “This type of reduction was simply not seen in previous years.”
Too early to declare victory
Dr. Muhammad Pate, head of the NPHCDA (and a World Bank staff member currently on external service), cautioned that it is much too early to declare victory against polio in Nigeria, and that vaccination efforts must be sustained, building on this recent success, before eradication can be achieved.
“The polio eradication effort is not only about polio—it is about delivering an effective vaccine to prevent a serious disease that depends on a functioning health system to succeed,” Pate noted. “Polio eradication can be a potent arrow head for transforming routine immunization and primary health care systems. Financial and human resources technical capacities for the Polio Eradication Initiative can be used to move the health systems agenda forward.”
“Lessons from the effective engagement with traditional leaders could find application in the effort to improve maternal and child health outcomes,” said Nair, “It has been hard to gain traction on this, particularly in Northern Nigeria, and so we look forward to more successes.”
The World Bank’s role
The polio program in Nigeria involves the harmonized efforts of many partners. The World Bank has provided US$135 million; approximately 25 percent of the funding needed for polio vaccines in Nigeria.
A unique feature of this operation is its “buy-down” nature. The buy-down mechanism aims to convert a normal International Development Association (IDA) development credit to grant terms through provision of external donor resources under clearly defined performance criteria.
In Nigeria’s case, donors, including Rotary International, Centers for Disease Control, U.N. Foundation and the Bill and Melinda Gates Foundation, have agreed to pay off the net present value of the debt once pre-determined performance indicators are achieved.
“As we near the goal of polio eradication, we need to move rapidly to strengthen routine immunization within an effective primary care delivery system,” concluded Onno Ruhl, Country Director. “It is unimaginable that while we have over 80 percent coverage for polio in all parts of country, the percentage of completely immunized children in some states is less than five percent. If we are to address this issue, it is critical to ensure effective performance management and increased incentives for health workers to deliver.”