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Health

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Ethical

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Current

Planning

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for Polio Eradication

Taylor, DPH, MD, MPH, FRCP(C) Felicity Cutts, MRCP, MD,


MBCHP, MSc, FFPHM, and Mary E. Taylor, MHS
Carl E.

Introduction

In 1988, the World Health Assembly


unanimously approved the goal of polio
eradication by the year 2000 with the
proviso that a global partnership should
strengthen health care systems.' As programs for a polio-free world intensify to
meet the end of the century deadline, there
are growing concems about the global
conmmiitment to support sustainable health
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A basic policy question is, How will
global goals and local priorities be balanced, and what are the ethical implications of current choices? The specific
underlying questions are as follows:
Should poor countries, with many health
problems that could be controlled, divert
their limited resources for a global goal
that has low priority for their own
children? When wild virus remains only
in a few sites, will rich countries, and the
global organizations they influence, promote eradication as a single-focus activity? Should poor countries expect donors
to improve upon past experience and use
the opportunity and financial benefits
from polio eradication to build sustainable
health systems for the world's neediest
children?
Who Will

:925).

Benefit Most from

Polio Eradication?
Progress

in eradication is most evi-

dent in countries that

established health

already

have well-

infrastructures.2-'

Now

those countries face the dilemma of how

long they

will have to sustain immuniza-

tion and surveillance costs. National


control
million

costs

the

annually,

about 76%

United States has had no cases of


wild-type poliomyelitis since 1979, an
average of nine cases each year have been
linked to oral polio vaccine.7 Thus, there
would be two immediate benefits for
countries such as the United States.
Globally, benefit-cost analyses
project that polio eradication benefits will
exceed costs by 2007, with cumulative
savings of $13.6 billion by 2040.8 Savings
are primarily in the cost of acute care and
rehabilitation from paralysis. Such savings accrue almost entirely in industrialized countries, because paralyzed children
in poor countries have little access to care.
Changing the "base case" assumption for
developing countries from 33% access to
0% access has virtually no effect on the
global benefit-cost analysis, while changes
in assumptions for industrialized countries have large effects.
Elimination of paralytic poliomyelitis will obviously benefit every country.
However, benefits for children in poor
countries must be balanced against many
more common threats to health and life.
Even in Southeast Asia and sub-Saharan
Africa, where polio incidence remains
highest, polio is responsible for less than
2% of years lived with disability.9 Poor
countries naturally give priority to problems such as pneumonia, malaria, diar-

United
which is

States

polio
$230

equivalent

to

of USAID contributions to

child survival worldwide.6 Also, while the

Carl E. Taylor and Mary E. Taylor are with the


Department of Intemnational Health, Johns Hopkins School of Hygiene and Public Health,
Baltimore, Md. Felicity Cutts is with the
Department of Epidemiology and Population
Sciences, London School of Hygiene and Tropical Medicine, London, England.
Requests for reprints should be sent to Carl
E. Taylor, DPH, MD, Department of International Health, Johns Hopkins School of Hygiene
and Public Health, 615 N Wolfe St, Baltimore,
MD 21205.
Editor's Note. See related comment by
Sutter and Cochi (p 913) in this issue.

June 1997, Vol. 87, No. 6

Public Health Policy Forum

rhea, measles, and malnutrition.'0 How


much of the global savings from polio
eradication will help poor countries address their priorities, especially considering that eradication is possible only with
the cooperation of such countries?

What Are the Costs, and Who


Pays?
Donor support for global immunization peaked with the Universal Child
Immunization Initiative in the early 1990s
and has declined since then." Extemal
funding for polio eradication is targeted
for polio vaccine procurement (especially
for National Immunization Days), international technical advisers, cold chain equipment, and laboratories for surveillance.
Developing country governments are expected to fund the remaining costs, and all
but the poorest countries are also expected
to finance an increasing proportion of
other Expanded Programme on Immunization vaccine costs. 12 In the Americas, host
governments and communities have contributed about 80% of polio eradication
costs.2 Major cuts in donor funding for all
health programs are being justified by
growing use of terms such as self-reliance
in financing services, decentralization,
and community participation.'3"4 When
local communities finance their own
health care, preventive services such as
immunization will have to compete with
other concerns. People reasonably compare benefits of polio eradication with
benefits of alternative services for their
children.
International contributions are increasingly earmarked for polio vaccines
and their delivery systems.8 The global
polio eradication strategy includes three
methods for vaccine delivery: routine
immunization services; National Immunization Days, conducted twice a year for 5
years with a goal of 90% coverage in
polio-endemic countries; and mop-up
vaccination in high-risk areas identified
by surveillance.3'5 It has been postulated
that high coverage with National Immunization Days, repeated for several years,
may be sufficient to eradicate polio.'5 This
would be a sharp break from accepted
policy, which stresses increasing vaccination coverage for all Expanded Programme on Immunization antigens and
effective surveillance to respond rapidly
to suspected polio outbreaks.'6 In the
African region, the average coverage rate
for infants for three doses of oral poliovirus vaccine was only 58% in 1995.
Experience with National Immunization
June 1997, Vol. 87, No. 6

Days has been mixed. Despite high


coverage of campaigns in eastern and
southern Africa, early reports suggest that
alternative community-based strategies
would provide more long-term benefits in
West African countries with weak health
infrastructure (R. Knippenberg, written
communication, March 1997). Little is
known about the effort and resources
needed for alternative strategies in the
poorest countries.
Estimates of vaccine delivery costs
through routine services, derived mainly
from studies conducted a decade ago,
range from $6 to more than $20 per child
for the original six Expanded Programme
on Immunization vaccines, with an average of $15.10,17 Community contributions
are typically much larger, especially for
activities, such as National Immunization
Days, that depend on volunteer and
intersectoral efforts. The opportunity costs
to communities and health services are
great, diverting time and effort from other
activities. In the past 15 years, structural
adjustment policies for economic reform
promoted by international banks have
caused governments to cut health care
budgets by a third to a half in most
sub-Saharan African countries.'8 Public
sector salaries are becoming increasingly
meaningless in some countries where
health workers live largely on per diems
from vertical programs. Any consideration of cost must include incentives
given to health personnel to compensate
for current public sector working conditions.19 Estimates are needed of the true
health investments required for hard-toreach groups in which wild virus strains
will presumably remain longest.
Eradication is, by definition, sustainable, since the virus would no longer
exist. However, this does not equate
automatically with developing the sustainable health systems implied in the World
Health Assembly resolution. Priorities in
low-income countries include safe motherhood, common childhood infections, tuberculosis, sexually transmitted diseases, and
family planning/reproductive health. '0
These programs differ from polio eradication in their target groups, control strategies, and need for sustained contact with
beneficiaries. Debates about how global
target-driven programs affect sustainable
primary health care have polarized policy
discussions since the 1978 Alma Ata
World Conference on Primary Health
Care. Both positive and negative lessons
were learned from eradication programs
such as the smallpox initiative.20 From the
malaria eradication efforts of the 1960s,

we should have learned not to extrapolate


successes from the rest of the world
automatically to the poorest countries in
Africa and Asia.2'

What Is the Past Experience?


Of particular value is the experience
of the 1980s. We summarize now the
results of two recent evaluations of the
impact of the Expanded Programme on
Immunization and polio eradication on
primary health care systems and the
sustainability of immunization programs."'22 (Carl E. Taylor chaired the
Commission on the Impact of the Expanded Program on Immunization and the
Polio Eradication Initiative on Health
Systems in the Americas.22 Mary E.
Taylor was the principal researcher who
gathered and analyzed field data and
wrote the report of the steering committee
for the United Nations Children's Fund
study."I Felicity Cutts was a member of
both evaluation teams.)
A 1995 report by a Pan American
Health Organization commission22 used
in-depth rapid assessment procedure methods in six Latin American countries representative of those with wild poliovirus
transmission in 1984. Positive and negative findings were carefully analyzed by
interviewing sizable samples of four
groups: polio eradication health workers,
health workers in other services, knowledgeable public officials, and community
representatives. Excellent support for this
2-year effort to gather objective information was provided by the Pan American
Health Organization's Polio/Expanded
Programme on Immunization group. The
overall conclusion was that polio eradication contributed positively to health systems and helped generate a "culture of
prevention" in these middle-income countries with well-established health infrastructures. Most positive was the promotion of social mobilization and intersectoral
cooperation, two of the Alma Ata primary
health care goals that have been the most
difficult to implement. The Expanded
Programme on Immunization strengthened managerial, epidemiological, and
laboratory capacity and was an important
catalyst for donor coordination. The management, laboratory, and surveillance systems helped in measles elimination activi-

ties.23
However, a common negative effect
in the poorer countries was that targeting
of immunization programs caused diversion of resources and effort at "the
expense of other health activities." NegaAmerican Journal of Public Health 923

Public Health Policy Forum

tive observations were made when social


mobilization produced excessive topdown pressure and "negative feelings
about repeated visits for only one purpose." A strong conclusion was that the
benefits of polio eradication in the Americas can be directly applied to policymaking only in countries with established
and sustainable health systems, strong
leadership at central and district levels, a
well-organized infrastructure, and local
ownership and decision making.
A 1995 United Nations Children's
Fund study" focused on the sustainability
of universal child immunization in achieving 80% coverage with all Expanded
Programme on Immunization vaccines by
1990. Case studies in six countries in
Africa and Asia, along with a desktop
review of global activities, were conducted. The greatest achievement was
reported to be raising the immunization
coverage of infants worldwide to 80% in a
short time period, although only somewhat more than half of developing countries reached 80%. Universal child immunization helped focus global attention on
prevention and demonstrated that services
could effectively reach the periphery.
However, the increase in global
coverage obscured problems in many
poor countries. In the African region, 25%
of countries reported 80% or higher
coverage for three doses of oral poliovirus
vaccine in 1990, but only 17% achieved
this rate in 1994/95.24 In the case study
countries, health service personnel said
that, because universal child immunization goals were set globally and negotiated politically, there was little local
involvement in setting targets, which were
imposed on national health systems and
communities. When health systems were
weak, universal child immunization tended
to override local delivery strategies and
create parallel and unsustainable systems
of financing, vaccine supply, transport,
and supervision. Top-down social mobilization increased apparent local participation, but communities were simply told
what to do. Conflict resulted between
local demand for integrated services,
especially essential drugs, and national
immunization targets.
When donor support for recurrent
costs waned after 1990, little capacity or
commitment to maintain coverage remained in poor countries. In an independent study in Ghana,25 a district medical
officer said, "The approach used was:
here is the money, go out! We want 80
percent by December." A 1992 review
reported that a rapid rise in coverage was
924 American Journal of Public Health

followed by a fall; the rate leveled off at


approximately 32%.

What Have We Learned?


Have the international agencies planning polio eradication heeded these lessons? Projections of high benefit-cost
ratios are based on time limits for different
regions.8 If implementation is delayed,
costs will rise substantially, as rich countries continue intensive surveillance and
mop-up activities. Gradually developing
programs will seem more costly than
originally anticipated. Benefit-cost ratios
are very different when seen from the
perspective of poor countries. Direct costs
from paralytic polio are low, and relative
risk judgments emphasize other priorities.
In any case, the costs of routine immunization must be met for a growing number of
vaccines.
Donors exert great influence on
health systems in poor countries; for
example, they contribute, on average,
19.5% of health expenditures in subSaharan Africa (40% or more in 13
countries), as compared with an average
of less than 2% in the rest of the world.26
We consider it shortsighted for donors to
use their considerable influence to promote polio eradication if this delays or
diverts long-term investment by poor
countries in sustainable health systems. It
would still be a good bargain for rich
countries to use projected benefits from
polio eradication to help build sustainable
health systems in poor countries. A solid
commitment by donors to long-term aid
(with clear process indicators) that builds
sustainable services could ensure continuing benefits in poor countries and reduce
the potential for the spread of other
diseases. Health systems development
should include community representation
in decision making, the shared setting of
goals and priorities, and local ownership
and control of resources and services.
Building of infrastructure was what
was promised in the unanimous World
Health Assembly resolution. The consortium of donors who have the most to gain
from rapid eradication should not only
bear most of the costs of eradication
activities but also fulfill that promise.
Polio eradication will be a gift to the 21st
century only if donors and governments
act in partnership to ensure long-term
benefits for the least developed countries
and poorest communities. O

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Erratum
In: Rasmussen KM, Adams B. Annotation: cigarette smoking, nutrition, and birthweight. Am J Public Health.

1997;87:543-544.
The name of the second author, Barbara Abrams, was incorrectly printed as Barbara Adams.

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American Journal of Public Health 925