Polio Evaluation AFG

7/24/2019 Polio Evaluation AFG

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Evaluation of the Global PolioEradication Initiative

Report on the

independentevaluation of themajor barriers tointerruptingpoliovirustransmission inAfghanistan

Michael Toole

Stephanie Simmonds

Benjamin Coghlan

Najibullah Mojadidi

Final Report

October 2009



Independent evaluation of the Global Polio Eradication Initiative, Afghanistan, August 2009

CONTENT OF REPORT

List of abbreviations

Acknowledgements

Executive Summary and Recommendations

Map of Afghanistan

CHAPTER 1: POLIO SITUATION IN AFGHANISTAN

CHAPTER 2: KEY COMPONENTS OF POLIO PROGRAM

CHAPTER 3: HEALTH SYSTEM AND SERVICE DELIVERYFACTORS AFFECTING PROGRAM PERFORMANCE

CHAPTER 4: COMMUNITY ISSUES AFFECTING PROGRAMCOVERAGE

CHAPTER 5: NON-HEALTH FACTORS AFFECTING PROGRAMPERFORMANCE

CHAPTER 6: TECHNICAL ISSUES THAT MAY BE BARRIERS TOERADICATION

CONCLUSIONS

Annex 1: Persons Met

Annex 2: Schedule

Stephanie SimmondsBen Coghlan

Michael Toole

Najibullah Mojadidi




ABBREVIATIONS

AFP Acute Flaccid ParalysisAGE Anti-Government ElementsAVA Afghanistan Veterinary AssociationBHC Basic Health CentreBPHS Basic Package of Health ServicesBVW Basic Veterinary WorkerCHW Community Health WorkerCIDA Canadian International Development AgencyDC District CoordinatorEC European CommissionEPI Expanded Programme on ImmunizationERC Expert Review CommitteeEPHS Essential Package of Hospital ServicesGAVI Global Alliance for Vaccines and ImmunizationICRC International Committee of the Red CrossISAF International Security Assistance ForceKAP Knowledge, Attitudes, and Practices

MoA Ministry of AgricultureMoPH Ministry of Public HealthMoPH-SM Ministry of Public Health – Strengthening MechanismMRRD Ministry of Rural Reconstruction and DevelopmentNEMT National EPI Management TeamNGO Non-Governmental OrganizationNID National Immunization DayNWFP North-West Frontier Province of PakistanOPV Oral Polio VaccineMDGs Millennium Development GoalsmOPV Monovalent OPVtOPV Trivalent OPVPEI Polio Eradication Initiative

PEMT Provincial EPI Management TeamPHD Provincial Health DirectorPRT Provincial Reconstruction TeamQIP Quick Impact ProjectRED Reach Every DistrictREMT Regional EPI Management TeamSIA Supplementary Immunization ActivitySNID Sub-National Immunization DaySOP Standard Operating ProceduresSOS Sustainable Outreach ServicesUNAMA United Nations Assistance Mission in AfghanistanUNDSS United Nations Department of Safety and SecurityUSAID United States Agency for International Development

VAPP Vaccine-associated paralytic poliomyelitisVFU Veterinary Field UnitWB World BankWHO World Health OrganizationWPV Wild Polio Virus




ACKNOWLEDGEMENTS

We would like to express our sincere appreciation for the excellent support, advice,and hospitality provided by the polio eradication initiative team at the central,regional, and provincial levels of Afghanistan. We were impressed with the level oforganisation, scheduling, logistics and security achieved in such a challenging

environment. We would particularly like to thank Dr Tahir Mir, Mr Mamdouh Samuel,and Mr Hamid Pason for helping to make our visit so productive and efficient.

We really appreciated having Dr. Najibullah Mojadidi work with us. His wise counselwas invaluable.

We recognise the extraordinary efforts made by the 54,000 people directly involvedin the national polio eradication initiative and are genuinely impressed by theremarkable achievements. We appreciate that many of our meetings were on Fridaysand Saturdays thus taking participants away from their families on these days of rest.

In a relatively short period of time, we were able to meet with polio eradication team-members from all seven regions and from 16 provinces. We realise that participationin these meetings required lengthy travel and valuable time away from work. We see

this as a reflection of a high degree of commitment to polio eradication.We extend our thanks to the many partners and stakeholders in the polio eradicationinitiative who took the time out to meet with us and share their knowledge andexperience, including the MoPH, WHO, UNICEF, UNAMA, CIDA, ISAF, the WorldBank, ICRC, USAID, OCHA, Ibn Sina, ADHS, and a number of NGOs in the EasternRegion (HealthNet, AMI, ARDC, BRAC, Hewad, CWSPA, and IMC).

Finally, we would like to express our sincere gratitude to our driver Habib, who wasour ever reliable guide and friend from early each morning till late in the evening.




EXECUTIVE SUMMARY

The polio eradication initiative (PEI) has achieved remarkable success in anincreasingly challenging environment. For the majority of the Afghan population(84%), ongoing polio transmission has ceased. Indeed, the range of wild polio virus(WPV) has reduced from six of seven regions in 2000 to four regions in 2009, and80-90% of all confirmed cases reported annually since 2006 have been from theSouthern region.

There is a very high level of political commitment, coordination by partners, andtechnical quality of PEI team work. The high level of planning, review, and analysis ofsupplementary immunization activities (SIAs) is impressive. There is regularcoordination with the PEI in Pakistan.

The high quality and coverage of acute flaccid paralysis (AFP) surveillance is beingmaintained, even in security-compromised areas. An independent evaluation in 2008found that it is highly unlikely that polio cases are missed in the four regionsassessed.

Despite the contraction of the area of polio transmission, the annual number ofconfirmed polio cases is not diminishing and appears to have remained static for the

last four years: 18 cases reported during 2009 up until mid-August is consistent withthe reported incidence in 2008. The reasons for this include non-health sectorbarriers, health system and service delivery barriers, community issues and potentialtechnical barriers .

Insecurity poses the most significant non-health sector barrier to achieving highpolio vaccination coverage throughout the country. The security situation is unstable,unpredictable, and threatened by a range of armed factions. Conflict-related andcustomary movements of large populations between Pakistan and Afghanistan andbetween provinces within the country have the potential to introduce WPV into areaswhere it has long been absent.

Changing policies of ISAF and Taliban, which focus not so much on pursuing theenemy but stabilising populations and enabling the provision of social services, offer

both opportunities and threats. Direct provision of vaccination by uniformedpersonnel must be avoided and the neutrality of the PEI must be protected andpromoted. High profile political endorsement of the polio eradication program mayno longer be appropriate and, in some security-compromised provinces, may have anegative effect. All government associated initiatives, particularly successful ones,are potential targets for anti-government elements. Similarly, supplementaryimmunization activities (SIAs) should be de-linked from events that risk aligning thePEI with real or perceived political agendas; for example, UN Peace Day.

The main health system and service delivery barriers to achieving polioeradication include significant disruption of routine EPI services by the high numberof SIAs; under-resourced health facilities, especially sub-centres; low salaries andincentives for vaccinators; inconsistent engagement in SIAs by NGOs contracted to

implement the Basic Package of Health Services (BPHS); inability to conductadequate supervision, monitoring and evaluation in insecure areas; inadequate EPIoutreach; a confusing number of donor initiatives; replacement of the experiencedNGO responsible for BPHS in Helmand Province; and lack of involvement of privatepractitioners in routine EPI services and SIAs.

The main community barriers include inadequate flexibility in accessing childrensafely. A number of examples of negotiation through different local intermediaries,including NGO district staff, hired negotiators, mullahs, and tribal elders, points to thesuccess of discrete, local negotiations with anti-government elements through a




flexible range of intermediaries. These examples also highlight that there is no single“right way” to engage with communities in security-compromised areas.

While there appears to be high community awareness and acceptance, poliovaccination is not perceived to be a high priority by most communities. Although maleelders, mullahs, and teachers have been engaged to mobilise communities, greaterefforts are needed to engage with individual male household heads to improvecoverage of birth dose OPV and to ensure that mothers make all their children,including newborns, sleeping and sick children, available for SIAs. Excellentinnovative strategies have been developed to mobilise women, however, theirapplication may be confined to narrow geographic areas.

A number of technical barriers to polio eradication may warrant further investigationand include the relatively high proportion of polio cases in children who havereceived more than ten oral polio vaccine (OPV) doses; evidence that several recentpolio cases occurred in children who were in contact with young adults recentlyreturned from Pakistan (and who may have diminished immunity and be sheddingWPV); lack of epidemiological evidence to continue the high number of SIAs inprovinces where WPV is not circulating; and lack of an adequate explanation of thehigh male: female ratio of reported polio and non-polio AFP cases

RECOMMENDATIONS

Short-term/Immediate

Primaryresponsibility

1.Promote the neutrality of the polio program.

1.1Reduce the visible involvement of political figures invaccination campaigns.

Government ofAfghanistan(GoA)

1.2De-link the SIAs from associated events that might be

used by anti-government elements to politicise the polioeradication initiative; for example, UN Peace Day.

United Nations,

ISAF

1.3Focus on discrete, local negotiations with anti-government elements through a flexible range ofintermediaries.

GoA and PEICountry Partners

1.4Finalise the draft standard operating procedures (SOP)for NATO/ISAF civil military engagement anddisseminate the guidelines to f ield personnel.

NATO/ISAF, UN

2.Devolve responsibility for detailed district-by-district, cluster-by-cluster planning of SNIDs, with flexible dates and flexible localapproaches to achieving access to communities.

2.1 Continue to expand the range of potential stakeholdersin facilitating access to high-risk districts. There needsto be more management risk-taking through discretenegotiation with a range of intermediaries includingNGO district staff, hired negotiators, mullahs, tribalelders, and district veterinarians, and direct negotiationwith AGE, to gain access to contested areas.

Provincial anddistrict PEI teams

2.2Consider add-ons (other than Vitamin A) to sub-NIDs,such as other health and non-health goods seen as

National PEIPartners




important by a community. Notice has to be taken ofwhat each community expresses as its priorities. Add-ons could range from bed nets (for the biting nuisance ofmosquitoes in areas where there is no malaria) or high-energy nutritious biscuits to vaccination for animaldiseases or improved water supplies.


3.Strengthen program management

3.1Urgently reconsider the criteria for selection of BPHSservice providers and provide greater weight to previousfield experience and ability to negotiate access tocommunities in insecure areas. This is an urgent priorityin Helmand Province.

Ministry of PublicHealth (MOPH)

3.2Tighten procedures for selecting cluster supervisors,volunteer vaccinator teams, mobilisers, and campaignmonitors to strengthen the ability of the program toassess and validate performance at the communitylevel.


3.3Clarify the role and responsibilities of health posts andCHWs in routine EPI and SIAs but also of other basichealth facilities, health personnel and otherstakeholders.

MOPH

3.4All categories of medical/nursing personnel incomprehensive and basic health centres and sub-centres should have vaccination included in their routineduty statements.

MOPH

3.5Address human resources constraints, such as lowsalaries of vaccinators and low incentives of volunteers.

MOPH/UNICEF

3.6Insist on a more effective engagement by NGOsimplementing BPHS in both routine EPI services andSIAs. Consider including performance incentives basedon survey-verified routine EPI coverage in NGOcontracts.

MOPH/WorldBank/USAID/EC

3.7Add a routine EPI indicator to the Balanced Scorecard. MOPH/Johns

Hopkins

Medium Term

PrimaryResponsibility

4. Maintain the neutrality of the polio program.

4.1 While ISAF is a key stakeholder in someprovinces/districts and should participate in planning andreview meetings, continue to give careful considerationto the nature of their role in actual service delivery.Uniformed soldiers directly providing health services insecurity-compromised areas may fuel local suspicionsthat activities such as immunization are part of the

ISAF/UN




military strategy and should be avoided.

5. Adjust the strategy of the polio program from regular, frequentnational immunization days to focused SNIDs in high-risk areas.

The current high frequency of NIDs and SNIDs is leading to fatigue,inability to conduct detailed strategic planning in high-risk areas,

disruption to routine EPI services in some fixed sites, and increasingly,resentment of the polio program by other mid-level health programmanagers.

We realise that reducing the number of NIDs in some other countries,without ensuring concomitant strengthening of routine EPI, has led tothe re-appearance of WPV transmission; for example, in Punjabprovince of Pakistan. Thus, implementation of this recommendationwould need to proceed with the utmost caution.

5.1 Reduce the number of NIDs starting in mid-2010 after arigorous technical analysis, which includes modelling oflikely immunity in each province, based on routine EPIcoverage, SIA access and coverage, and exposure to

migrants from areas where WPV is circulating. The sixNIDs planned for 2009 should be conducted asscheduled.


5.2 Reduce the number of NIDs in a carefully phasedmanner; for example after careful analysis of likelyimmunity, a NID could be replaced by a SNID consistingof as many as 33 of the country’s 34 provinces. Theexcluded province(s) could be chosen on the basis ofthe performance of the relevant BPHS NGOs inachieving high coverage of OPV4 in 0-18 month olds.

Critical in this process is the performance of NGOscontracted to implement BPHS (see 3.6).


5.3 Continue to pilot and evaluate innovative methods ofcommunity mobilisation, such as “women’s courtyards”,district and sub-district level volley-ball, football andcricket games, and cluster jirgas of community elderswhile recognising that such strategies may only beacceptable within relatively narrow geographic areas.

UNICEFcommunicationofficers;provincial anddistrict PEI teams

5.4 While men, such as mullahs, tribal elders and teachers,are already being engaged by the PEI to mobilisecommunity support for SIAs, more attention should betargeted at individual male heads of households.


5.5 Consider piloting group education sessions in different

regions for “expectant fathers” either at health facilitiesor traditional meeting places, such as mosques. A keymessage is the importance of the birth dose of OPV (andHBV), but could be combined with other importantmessages related to maternal and newborn health, suchas early warning signs of labour and pregnancycomplications, nutrition, and neonatal tetanusprevention.

Provincial and

district PEI teams




5.6 Maintain intensive cross-border immunization and closecoordination with PEI activities in Pakistan.

In addition to synchronising the timing of SIAs,synchronise communication strategies with Pakistan.

National PEIPartners;provincial anddistrict PEI teams

5.7 Actively seek collaboration and coordination with the

national animal health program, with its network of 625veterinary field units, veterinarians, paravets, and basicveterinary workers. This collaboration should particularlyinvolve the Afghanistan Veterinary Association (AVA)which has many members in the southern provinces.

MOPH, WHO,

Ministry ofAgriculture andLivestock, AVA

6. Increase base level of immunity in children through strengthenedroutine EPI services

6.1 Strengthen routine EPI services in all parts of thecountry to achieve 90% coverage by OPV4 throughbetter resourcing of health centres at all levels,accelerated outreach (mini-SIAs), and more mobileteams.

MOPH, UNICEF,WHO, and BPHSNGOs

6.2 Standardise population denominators by conducting atechnical workshop to review the current range ofpopulation estimates (between 26 and 33 million) andagree on a single figure for coverage of EPI and otherhealth programs, such as antenatal care.

MOPH, WHO,UNICEF

6.3 The presentation of district EPI coverage data ideallyshould include comments on recent populationmovements if known to give an idea of recent changes innumerators and denominators.


6.4 Harmonise donor initiatives to strengthen routine outreach and mobile EPI services such as Sustainable

Outreach Services (SOS), Reach Every District (RED),and Quick Impact Projects (QIP).

MOPH, WHO

7. Maintain the high quality of AFP surveillance

7.1 Expand surveillance in districts reporting fewer than 2AFP cases per 100,000 per year by recruiting newcommunity informants, such as Basic VeterinaryWorkers (BVW).

MOPH, WHO

7.2 Institute measures to improve the timeliness of casenotification and investigation in order to reduce thenumber of inadequate cases and recall bias in theinvestigation.

MOPH, WHO

7.3 Strengthen the link between AFP surveillance andservice provision in order to maintain commitment to thesystem. More generally, there is a need for feedbackmechanisms for other vaccine preventable diseases(VPD) listed as nationally notifiable diseases, which is away of ensuring that polio surveillance activities do notweaken other VPD surveillance.

MOPH, WHO

7.4 Strengthen coordination of AFP surveillance inAfghanistan and the border areas of Pakistan and with

MOPH, WHO




other states bordering Afghanistan.

8. Strengthen program management.

8.1 Address resource constraints at the sub-centre level andclarify the responsibilities of nurses and midwives inimmunization in the absence of designated vaccinators.

MOPH

8.2 Consider including under-five nutritional status andaccess to clean water and sanitation in the indicatorsused in the gap analysis to identify high-risk districts.


8.3 Involve private practitioners and non-health serviceproviders in both routine EPI and SIAs.


8.4 Involve a broader range of stakeholders to enableadequate supervision and M&E of routine EPI and SIAs.


8.5 Develop communication strategies to improve theretention rate of routine immunization cards.

MOPH, UNICEF

8.6 Clarify referral procedures for AFP cases that require

rehabilitation services. Currently, most provincialhospitals have inadequate physiotherapy capacity toprovide effective care. The ICRC will cover the cost oftreatment and transport to their six orthotic centres.

MOPH

Longer Term

9 Conduct operational research to clarify the following issues

9.1 – Polio infection in children with high number of OPVdoses.

– Possible infection of some children by older childrenor adults returning from Pakistan.

– High male: female ratio of reported AFP cases.

WHO

10. As polio case numbers decline with improvedimmunization coverage, strengthen the quality of thereview of ‘inadequate’ AFP cases.

10.1 This could be achieved by ensuring in-person review bymembers of the ERC, and/or strengthening the capacityof AFP focal points to collect sufficient clinicalinformation for the ERC to make a firm diagnosis (e.g.videos of clinical examinations; access to medicalinvestigations and imaging) and to follow-up cases forthe requisite period.

MOPH, WHO

10.2 Although the reasons why cases were ‘inadequate’ areroutinely reviewed within the current system, thispractice may also need to be improved. In particular,lessons learned from individual cases about how toimprove early detection should be shared with allsurveillance system stakeholders.

MOPH, WHO




Map of Afghanistan




CHAPTER 1. POLIO SITUATION IN AFGHANISTAN

Geographical distribution of polio cases, 2000-2009

For the majority of the Afghan population (84%), ongoing polio transmission hasceased. Indeed, the range of wild polio virus (WPV) has reduced from six of sevenregions in 2000 to four regions in 2009, and 80-90% of all confirmed cases reported

annually since 2006 have been from Southern region alone. Of these, three-quarterswere detected in just 10 insecure districts within the region (Dihrawud, Kandahar,Maywand, Nad Ali, Panjwayi, Sangin, Shah Wali Kot, Spin Boldak, Tirin Kot, MusaQala). Despite the contraction of the area of polio transmission, the annual number ofconfirmed polio cases is not diminishing and appears to have remained static for thelast four years.

Confirmed cases of polio P1 and P3 [and compatible cases], 2000-09

Region 2000 2001 2002 2003 2004 2005 2006 2007 20082009

(Jan – Jul)

Central 3 - 1 - - - [1] - - - 1

Southern 11 9 [6] 5 [1] 3 [1] 3 [1] 9 [3] 28 [6] 15 [2] 25 [1] 15 [2]

South Eastern 5 1 [2] - 2 - - - - - -

North 1 - [1] - - - - - - - [1] -

North East - - [7] 2[4] - - [1] - 1 - - [1] -

Western 4 - 1 [1] 1 [2] - - 1 - 3 1

Eastern 8 1 [1] 1 1 [1] 1 - 1 2 3 1

Country 32 11 [17] 10 [6] 7 [4] 4 [2] 9 [4] 31 [6] 17 [2] 31 [3] 18 [2]

Confirmed (P1 and P3) and compatible cases of polio, 2000-09

22

10

5 42

5

29

6

25

14

10

1

5

3

2

4

2

11

6

4

17

4

6

2

3

2

2

6

4

0

5

10

15

20

25

30

35

40

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

(Jan-

Jul)

N u m b e r o f c a s e s

P1 P3 Compatible

Polio serotypes and relationship of reported cases with cases in Pakistan

Three-quarters (76%) of viral isolates since 2006 have been serotype 1 (P1) and24% serotype 3 (P3). Southern region and Farah province of Western region haveongoing transmission of indigenous P1 and P3 viruses. P1 isolates are part of thesame cluster (A-3A) of the single remaining local lineage of P1 viruses inAfghanistan, although the degree of genetic variation of some of the isolatesindicates prolonged, uninterrupted (and unidentified) circulation. These viruses arerelated to isolates from Pakistan (Balochistan and northern Sindh) and are indicativeof the customary large scale population movements between these areas.




The few cases occurring outside the southern polio transmission zone have alsobeen linked with isolates from Pakistan. P3 viruses from Eastern children in 2008 aresimilar to viruses circulating in the North West Frontier Province (NWFP) (cluster B-1C), and the two P1 cases identified in Central and Eastern region in 2009 weregenetically related to isolates in NWFP (cluster B-4A). Both of these latter caseswere also loosely linked to young adult contacts with recent travel to this area of

Pakistan.

No cases of paralysis from vaccine derived polio viruses have been detected to date.

Age, gender and vaccination status of polio cases

Except for 2000 and 2003, more than 75% of children diagnosed with polio havebeen aged less than 36 months. More boys than girls have been affected.

Since 2006, just over half the cases were among children who received fewer thanthe expected number of OPV doses (21% had not received a single dose; 34% weregiven between one and three doses). The remaining children were reportedly givenfour or more doses (3% received four doses; 21% between 5 and 10 doses; and 22%more than 10 doses), raising concerns about correct reporting of doses given,viability of the vaccine or other factors interfering with the development of immunity.

The social characteristics of cases from Southern region and Farah province of Heratin 2008-09 were examined. The majority were from fixed communities (95%) in ruralareas (73%) distant from health facilities (average distance: 22km) and with noaccess to clean drinking water (85%).

Doses received, age and sex of confirmed cases of polio, 2000-09

Measurement2000

(n=32)2001

(n=11)2002

(n=10)2003(n=7)

2004(n=4)

2005(n=9)

2006(n=31)

2007(n=17)

2008(n=31)

2009(n=18)

Median 2.0 4.0 7.0 6.0 6.0 9.0 4.0 2.0 3.0 1.0

Mean 2.7 4.8 5.8 6.4 8.3 9.4 6.1 4.4 5.7 6.5

Min 0 2 1 0 3 4 0 0 0 0

Max 9 8 12 14 18 17 28 16 17 25

Doses received

>3 19% 73% 70% 63% 75% 100% 52% 35% 48% 33%

Median 22.5 13.0 13.0 20.5 27.0 20.0 18.0 18.0 18.0 18.0

IQR 17-48 11-18 11-23 14-51 22-35 14-30 16-30 11-24 14-24 12-35

Mean 36.2 14.5 15.3 39.3 29.5 22.8 24.4 19.9 26.5 24.2

Min 9 7 1 7 16 10 8 3 9 8

Age of child

Max 148 24 30 120 48 42 120 72 96 54

Sex ratio (M:F) NA NA NA NA NA NA 1.2 2.4 1.8 1.2

Doses received and age of compatible cases of polio, 2001-09

Measurement2001

(n=17)2002(n=6)

2003(n=4)

2004(n=2)

2005(n=4)

2006(n=6)

2007(n=2)

2008(n=3)

2009(n=2)

Median 4.0 4.0 5.5 0.5 5.0 8.0 9.5 13.0 1.5

Mean 5.1 4.2 5.3 0.3 2.8 7.0 6.8 11.0 1.3

Min 0 2 0 0 2 2 4 9 1

Max 9 7 10 1 15 17 15 14 2

Doses received

>3 59% 67% 75% 0% 50% 83% 100% 100% 0%

Median 30.0 12.0 15.5 30.0 22.5 18.0 40.0 36.0 13.0

IQR 19-48 10-15 13-24 27-33 15-59 17-21 35-45 27-42 11-16

Mean 37.6 12.5 21.0 30.0 52.0 18.8 40.0 34.0 13.0

Min 5 8 13 24 7 14 30 18 8

Age of child

Max 96 18 40 36 156 24 50 48 18

Sex ratio (M:F) NA NA NA NA NA 1.5 1.0 0.5 1.0




AFP surveillance data analysis, including gender and vaccination status

Compared to confirmed and compatible cases of polio, cases of non-polio AFP areolder and have had more doses of OPV. Boys are more likely than girls to bediagnosed with paralysis caused by polio or a non-polio condition. It is not clear if thisis due to reporting bias or real differences in risks, exposures, treatment or immunity.

Doses received and age of cases of non-polio AFP, 2006-09 Criteria 2006 (n=952) 2007 (n=1097) 2008 (n=1348) 2009 (n=676)

Mean 52 51 49 51

Median 36 36 36 36Age of child

Range 0-179 0-179 0-179 0-177

Mean 12 12 13 13

Median 12 12 12 13Doses of OPV received

Range 0-36 0-32 0-36 0-33

Sex of child Sex ratio (M:F) 1.4 1.3 1.2 1.3

Active surveillance in some regions (Western, Central) has declined in 2009compared to previous years. Surveillance links with the border areas of Pakistan areweak and recommendations to strengthen links with central Asian states have not yetbeen implemented. It is unclear if the system could detect cases of polio in olderchildren or young adults (see chapter 2 for more details about the surveillancesystem).

Vaccine associated paralytic poliomyelitis (VAPP)

The polio eradication initiative also reviews AFP cases to determine if there havebeen cases of VAPP. From 2001 to 2007 there were 3 cases with classic clinicalsigns of paralytic polio, recent vaccination with OPV and isolation of a Sabin-likevirus from stools.

SIA coverage data by region/province/age/gender

Multiple methods are used to assess coverage of NIDs and SNIDs (see Chapter 2).

Post campaign analysis in individual clusters in 2009 found that coverage exceeded90% in the majority of surveyed clusters with the exception of those in the Northeast(mean of 19% of clusters) and North (24%) regions, and combined South region andFarah province of West region (50%).

Other assessments bear out these trends: finger mark surveys in markets in South/Farah have been consistently below 80% in 2009 whereas other regions haverecorded coverage above 90%; surveys of households around AFP cases confirmpoor coverage in the South compared to elsewhere in the country; and southernchildren identified with non-polio AFP have received a lower number of total OPVdoses relative to cases living in other parts of Afghanistan despite having had thehighest number of SIAs conducted in 2009. Furthermore, some districts in the Southhave been inaccessible purportedly due to insecurity, and assessments of campaign

quality have been unsupervised in parts of Southern region.

Routine EPI (OPV3) data by region/province/age/gender

Estimates of routine EPI coverage are uncertain because the target population is notprecisely known (see chapter 2 for range of figures). Population movement may alterlocal targets and service providers may intentionally select lower denominators toinflate the coverage they achieved. For example, household surveys of EPI coveragearound AFP cases, which are fairly randomly distributed throughout Afghanistan,generally show much lower coverage than reported by routine EPI providers and wellbelow benchmark levels. Similarly, less than 80% of non-polio AFP cases among




children aged 6-23 months detected in 2009 had received 3 or more doses throughthe routine EPI service in all regions except Central. In South region and Farahprovince less than a quarter of these children had been vaccinated 3 or more times.Differences in EPI data for doses given at the same age indicate that there arepersistent problems with delivery of early doses of OPV – for instance, while thenational coverage of BCG is high (87%), the birth dose of OPV, which was

introduced in 2004, is poorly delivered (38%).

Comparison of routine EPI coverage from household surveys and administrative reports, 2006 vs 2009

2006 2009Region Routine EPI coverage from

household surveys*OPV3 coverage from

routine EPI dataRoutine EPI coverage

from household surveys*OPV3 coverage from

routine EPI data

Central 36-85% 71% 57-89% 77%

Eastern 71-80% 87% 68-87% 110%

Northeast 36-62% 72% 57-67% 88%

Northern 37-80% 70% 32-76% 90%

South Eastern 23-66% 77% 47-63% 78%

Southern 5-56% 45% 6-38% 63%

Western 20-72% 77% 39-78% 80%

* Range in mean routine EPI coverage from surveys of households about AFP cases in provinces within region

Findings of Knowledge, Attitude and Practice (KAP) surveys

Community based KAP studies conducted throughout Afghanistan in 2008 found thatwhile most people knew about the polio immunization campaign itself, fewer wereaware that multiple doses of OPV were necessary (54%) or that OPV would preventparalysis (43%). Even fewer respondents identified paralysis as a sign of polioinfection (39%) or knew that there was no effective treatment (19%).

If a child did not receive OPV during an SIA, parents were asked the reason why.Frank refusals were uncommon and have been significantly reduced following socialmobilisation activities. The most commonly cited reason was that the child was nothome. Investigations are currently underway to assess if this was actually a passivemeans of refusal. Parents also refused because their child was sick, sleeping or

newborn. In the South, West and Northeast, however, a significant proportion ofmissed doses were because the immunization team did not visit the house.

Summary

Indigenous WPV of both serotypes persists in the most insecure areas of southernAfghanistan (including Farah province of Western region) where immunity is low dueto inadequate OPV coverage rates from routine EPI and SIAs. Sporadic cases inother regions with viruses related to isolates from neighbouring areas of Pakistanhighlight the need to maintain surveillance and immunisation coverage.

The sizeable minority of cases who received more than four doses of OPV raisesquestions about why these children did not develop protective immunity. The reasonswhy more boys than girls have had confirmed and compatible polio and non-polio

AFP remain unclear, but reporting bias needs to be excluded. Most cases are amongchildren aged less than 36 months and in most cases reflect a failure of both routineEPI and SIAs.

Despite the limitations of the context, the surveillance system for AFP is highlysensitive and representative, and produces high quality, useful data. There remainissues of delayed reporting in remote and insecure communities limiting virologicalconfirmation in a minority of cases.

Coverage data of SIAs and routine EPI from multiple sources show continualimprovement from year to year in all regions except the South where access is




restricted and verification is difficult. Administrative reports of EPI coverage areconsistently higher than data derived from other sources and may be overestimatingcoverage particularly among younger children. In part, this is due to the inconsistentapplication of denominators to calculate routine coverage.

KAP studies have identified reasons for failure, some of which require additionalqualitative investigation. Most are potentially modifiable with tailored pre-campaignsocial mobilisation activities and improved supervision and verification of teamperformances.

Wild PV in Afghanistan, 2009

B-4A

A-3D

A-3A

PEND

Data up to 1 Aug 09

NSL1

NSL3

Southern Region: only area with continued

indigenous WPV transmissionincluding Farah (A-3A lineage circulationsince 2007)

Eastern Region: cross-borderinfection / re-infection from NWFP/

tribal areasB-4A, B-1C & B-4A




CHAPTER 2: KEY COMPONENTS OF POLIO PROGRAM

Main components of national strategy

The main elements of the polio eradication initiative (PEI) are:

• Strengthening routine EPI, including OPV4 dose at 18 months of age.• Supplementary immunization activities (SIA), including national immunization

days (NID) using trivalent vaccine, sub-national immunization days (SNID),using either trivalent or monovalent vaccine, and cross-border vaccination.

• Acute flaccid paralysis surveillance.

These activities also include cross-cutting activities, such as communication andcoordination; monitoring, evaluation, and review.

National, provincial and district level structure and responsibilities

Oversight of SIAs is provided by a national EPI management team (NEMT), includingMoPH, WHO, and UNICEF. There is also a national inter-sectoral committee (PolioAction Group), with review and coordination functions.

There is an equivalent team at the regional (REMT) and provincial (PEMT) levels,that includes WHO regional and provincial polio officers and UNICEF poliocommunication officers. There are regional and provincial coordination committees,the latter chaired by the provincial health director (PHD).

District coordinators (DC) are usually appointed by the NGO responsible forimplementing the BPHS. DCs and district coordinating committees select clustersupervisors, who in turn select two volunteers at each sub-cluster (village) level. Inhigh-risk districts, there are district and cluster communication focal points.

Frequency of NIDs and SNIDs

Six NIDs using trivalent vaccine and five SNIDs using either trivalent or monovalentvaccine have been planned for 2009. NIDs were conducted in January, March, Mayand July and are scheduled for October and November. In February, a SNID

provided measles vaccine and OPV (mOPV1 in three southern provinces – Nimroz,Helmand, and Kandahar -- and mOPV3 in three eastern provinces – Nangahar,Kunar, and Laghman -- and one south-eastern province, Paktia). In April, a broaderSNID using mOPV1 included all southern, eastern, and south-eastern provinces andFarah in the western region. There have also been “mop-up” campaigns comprisingshort-interval additional OPV doses.

A SNID in 13 southern districts is planned for September 13-15; however, the originalplan to use mOPV1 may need to be revised since three cases of polio type 3 havebeen reported in Helmand and Kandahar during the past two months. A further SNIDin southern, eastern, SE, provinces and Farah is scheduled for December.

Organization of NIDs and SNIDs

Provincial and district coordination committees oversee pre-campaign advocacy andsocial mobilization involving meetings with provincial and district governors andcouncils, shuras, and messages through the mass media. Each cluster supervisorsupervises a varying number of village vaccinator teams (average five), dependingon the geographic terrain, population density, and distances between villages. Inmany areas, Imams, community elders, and teachers have been engaged to mobilizecommunities. In several campaigns, there have been high-profile launches by thePresident, Ministers, provincial governors, and UN agency country representatives.




NIDs represent a massive mobilization of human resources. Around 54,000 peoplewere directly involved in the last campaign, including 46,500 volunteer vaccinatorsand 1,300 community mobilisers.

In April 2009, total responsibility for implementing SIAs was handed over to NGOswith BPHS contracts in seven districts of Helmand and Kandahar on a trial basis.

Detailed micro-planning has been promoted right down to the cluster and villagelevels. Cluster supervisors conduct monitoring, supervision of village teams, anddaily performance reviews during campaign days and community mobilisers facilitateaccess by vaccinators to households. Post-campaign assessments are conducted byindependent monitors (teachers, students, etc), including finger-marking surveys inmarkets of vaccination coverage and analyses of the reasons for missed children.Each monitor visits at least three team areas and at least ten families in each area.

Household Monitoring Form

Approaches to less accessible areas

High-risk districts have been identified using a gap analysis that includes a range ofvariables, including vaccine coverage, reported polio cases, and health serviceaccess. In these mostly security-compromised areas, a range of intermediaries havenegotiated access to communities, including NGO and MOPH staff, hirednegotiators, and non health sector personnel. Communication strategies havedeliberately designed to target these high-risk districts. Further discussion on access

can be found in chapter 3.

Communication and social mobilization

The communication strategy seeks to be evidence-based, targeted to addressdocumented gaps in knowledge, promote immunization seeking behaviours andcapitalize on opportunities. The strategy has been informed by KAP surveys, pilotstudies, annual national reviews since 2006, regional meetings, and a high-levelmeeting in Geneva in 2007. The communication strategy is now firmly targetedtowards high-risk populations in 13 high-risk southern districts. Communication

c h i l d r e n r e p o r t e d

l i v i n g i n h o u s e


v a c c i n a t e d


l i v i n g i n h o u s e


v a c c i n a t e d

T o t a l

W i t h F i n g e r

M a r k i n g

T e a m n o t c o m e

A b s e n t

N e w b o r n

S i c k

S l e e p

G u e s t

R e f u s a l

Yes No

R a d i o

T V

M u l l a h

T e a c h e r

C H W

C o m m u n i t y

l e a d e r

P o s t e r s

v i l l a g e w o m e n

N o n e

Market= M Travelling=T School=S Relative House=R Working in the field=F RH

Household Monitoring Checklist - : Round:

H o u s e N o F r o m D o o r M a r k i n g

n u m b e r f a m i l i e s l i v i n g i n

h o u s e

Vaccination teams going house-to-house yes [ ] no [ ] Mosque Announcements Made : yes [ ] no [ ]

Team Visited the area : yes [ ] no [ ] Team No :________

Correct

Door

marking

Specific

Address/Name of

Head Household

( 90

Coverage % = (vaccinated/Totalchildren in house)*100

100

After visiting the 10 houses go and find team/supervisor and check back of Tally sheets. How many of the children you

have listed as absent are recorded by the team on the back of tally sheet [_________ ] [________ % ]

(

Missed Area: (If 3 or more houses are missed in 10 houses) Yes [ ] No [ ]

Cluster ________________ Village/Street. _____________________ _ Date________________

Province____________ District ______________ Name of Monitor _______________ Agency/Organization__________

% %

Communication data Children

seen by

monitor

Poorly Covered Area:(If 4 or more children are missed or coverage is less than 90%) Yes [ ] No [ ]

Total :

Children <5

years of age

How many ofthem are <1

year?

Reasons for Missed

F

I f t h e c h

i l d i s

a b s e n t g i v e t h e

r e a s o

n s

a c c o r d i n g

t o t h e

c o d

e

MTS

How did you hear about NID?( Yes or No)




action plans are integrated into SIA micro-planning at the cluster and sub-clusterlevels.

In addition to communicatingthrough mass media (print, radio,and TV), innovative means havebeen used to communicatemessages locally via sportingevents, parades, and a women-to-women strategy through Women’sCourtyards . Jirgas , or traditionaltribal assemblies, including mullahs,community elders, and teachers,have been convened to promotevaccination. A radio serial NewHome New Life was developed inPashtun through a partnership withthe BBC Trust.

The effectiveness of various

approaches in achieving high OPVcoverage has been evaluatedthrough random cluster surveys. Forexample, in Spin Boldak district ofKandahar, after implementing atargeted communications strategy in2009, the refusal rate during SIAsdeclined from 34% in April to 23% inMay to 14% in June.

In Kandahar City, SIA coverage in June 2009 was 99% in clusters where thewomen’s courtyard approach was used compared to 91% in other clusters.

Post-campaign assessments continue to find relatively high numbers of “absent

children”, including newborns. There is some concern that these children represent“silent refusals” and will be the subject of ongoing qualitative research. Micro surveyshave been planned over three rounds to gather qualitative data about “absentchildren”.

Cross-border activities and coordination with Pakistan

Around 1.5 million children are vaccinated with OPV annually at 11 border crossings.In 2008, more than 800,000 children were vaccinated at the Torkham border post. Inareas that are traversed by semi-nomads, such as Khost and Farah, mapping ofmovements and focused social mobilisation has achieved high OPV coverageamong these groups. NIDs in the two countries are synchronised, with Pakistancommencing their campaigns on Day 3 of the Afghan campaigns. There are frequentmeetings between Afghan and Pakistan PEI teams, both centrally and locally.

Chapter 5 discusses further the issue of population mobility.

Routine EPI system

The National EPI Department was established in October 2002. Routine vaccinesinclude HBV and HiB. The program receives co-financing from GAVI, which hasenabled expansion of the cold chain to accommodate 120 million doses of vaccine.There have been no stock-outs of EPI vaccines since 2006.

Routine EPI is largely provided through fixed sites – district hospitals, comprehensiveand basic health centres, and sub-centres, the latter covering a catchment of

Women’s Courtyard in Jalalabad District,Nangahar Province




approximately 3,000 people. In the majority of these facilities, there is a distinctcategory of health worker – vaccinators – who deliver EPI (see chapter 3). Shortagesof vaccinators were reported in many sub-centres. In most areas, EPI outreach andmobile teams are poorly developed; however, several donor initiatives are seeking tostrengthen these services, e.g. sustainable outreach services (SOS), reach everydistrict (RED) and quick impact projects (QIP). NGOs implementing BPHS are

responsible for routine EPI services. An estimated 18% of the country’s districts areclassified as Grade IV, with poor access to and low utilisation of fixed health facilityservices.

Estimation of EPI coverage by the administrative method is complicated by imprecisepopulation figures – a lower figure (26.5 m) based on Census Statistics Office data isused to estimate EPI targets and a higher figure, based on UN statistics (28.1m), isused to estimate procurement needs. The CIA estimates the population ofAfghanistan in 2009 to be 33 million. EPI targets based on under-estimatedpopulation figures result in over-estimation of EPI coverage. Thus, we heard nationalDPT/HBV/HiB/OPV3 coverage figures ranging from 35% to 85%. UNICEF/MoPH areplanning to conduct a Multiple Indicator Cluster Survey later this year, which willprovide an opportunity to gain accurate immunization coverage data.

Roles of non-health sector

ISAF/NATO has been actively engaged in supporting the PEI since early 2009. OnJune 17, senior commanders were briefed on the PEI. ISAF has agreed to theconcept of “Days of Tranquillity” during SIAs in 13 insecure southern districts,although it is not clear what this means in practice if there is not concurrent consentby local AGE commanders. ISAF is able to provide logistical support and to ensurethat no offensives occur on SIA days. Local ISAF commanders coordinate and shareinformation on operations with UNAMA and local NGOs. There appears to beagreement at the high command level that ISAF personnel should not directlyprovide vaccination services.

The Canadian commander of the Kandahar ISAF base suggested that negotiationwith local AGE commanders could be mediated through “local contacts” of the

Canadians. In addition, he suggested that ISAF “real-time” intelligence on the truestatus of security in high-risk areas could help allay the fears of vaccination teamsand monitors. The Canadian military has regularly participated in SIA planning andreview meetings in Kandahar.

Other organizations that have played an active role in SIAs include ICRC andUNAMA. Both agencies have been able to communicate with AGE in some areas topromote community mobilisation in insecure areas.

System of AFP surveillance

The review of the AFP surveillance system in four regions (North, NW, West, andCentral) in 2008 found the system was highly representative and sensitive. Whencombined with the active case finding conducted during SIAs, it was considered

unlikely that paralytic cases of polio would be missed in these regions. Thesurveillance network includes approximately 10,000 community volunteers, 500district focal points (physicians, paediatricians, etc), 34 PEMTs and seven REMTs.Reports are compiled on a weekly basis. Although the non-polio AFP rate in 2009was lower in insecure compared to secure areas, they remain high by internationalstandards (in non-endemic countries) in all provinces except Urozgan, and provincialstaff are confident that cases would still be reported even when access for SIAs wasrestricted. However, some districts have reported AFP case rates of less than 1 per100,000.




Performance indicators in most provinces meet international benchmarks. The fewexceptions are delays in case investigation and stool collection in remote andinsecure sites. The higher than expected rate of detection of cases of AFPthroughout Afghanistan can be partly explained by the deliberately liberal casedefinition adopted to maintain a highly sensitive system.1 It may also be due to a highburden of non-polio enteroviruses given the high percentage of EV isolated from

stool specimens (and the high proportion of AFP cases attributed to Guillian BarreSyndrome2).

AFP cases where a stool specimen is collected more than 14 days after the onset ofparalysis are reviewed by a regional panel and then referred to an expert reviewcommittee (ERC) in Kabul.

Afghanistan: Non-Polio AFP Rate by Province, 2007 to 2009

2009

2008

2007

0-0.991-1.99

2-4.99

5+

Data up to 6 Jun 09

Note that the surveillance review in 2008 found that health workers in Afghanistan may not apply thecase definition for AFP as ‘liberally’ as health staff in other endemic countries. Additionally, they may beerroneously excluding cases initially reported as AFP.

Note that the 2008 surveillance review team thought that there was an unusually high proportion ofnon-AFP cases attributed to Guillian Barre Syndrome.




CHAPTER 3: HEALTH SYSTEM AND SERVICE DELIVERY FACTORSAFFECTING PROGRAM PERFORMANCE

The Afghan health system

Afghanistan has impressively developed its health system from a ministry run bymullahs under the Taliban pre-2002 to a system that has the capacity to address

local and national priorities as well as international concerns such as the healthMDGs. Equity and the right to health have been key values of the Ministry of PublicHealth (MoPH) since 2002. When considering polio eradication the current keyhealth system challenges are to do with political leadership, roles and responsibilitiesand management style and practices.

Political leadership – There has beenhighly visible political leadership of thepolio eradication initiative inAfghanistan. At different times, thePresident, Minister of Health, andgovernors of provinces have all takenturns to lead NIDs and sub-NIDs. This

worked well in the past; it was the rightthing to do then and it produced goodresults. However, now is the time topromote the neutrality of the program,and to distance it from any political,institutional, organisational, and militarylinks. The health system has to adaptand take risks in developing differentways to achieve eradication such asbuilding local trust, developingnegotiating skills and reducing fear.

For a fuller discussion of the advantages and disadvantages of high profile politicalendorsement of polio campaigns see chapter 5.

Roles and responsibilities – Clarity and understanding about roles andresponsibilities is a key health system characteristic. Even more so in the conflictaffected context in Afghanistan where there is a multitude of local and internationalstakeholders, each determined to play a well-intentioned role in the PEI. The MoPHis in the driving seat and needs to play a leading role in defining the responsibilitiesof the many partners in the program.

Key international partners providing technical support are the World HealthOrganization (WHO) supporting AFP surveillance, SIAs, and routine EPI andUNICEF overseeing communications and some aspects of EPI such as the coldchain, vaccine procurement, and support for vaccinator per diems. While theseaspects of the program are almost faultless, its management needs attention. Thesound technical analysis, implementation and surveillance have tended to take

precedence resulting in the relative neglect of key management factors hamperingachievement of results. The following sub-section on management style andpractices has further detail.

Funding is from a number of donors including Rotary International, the CanadianInternational Development Agency (CIDA), and the Japanese InternationalCooperation Agency. CIDA has taken a particular interest in implementation of thepolio eradication program in Kandahar province where the Canadian military isplaying a lead role in the fight against insurgency – see chapter 5 for a discussion ofissues related to governments being both aid donors and combatants.

President Hamid Karzai and publichealth minister Dr. Muhammad AmenFatimi launch the NID in July 2009




As outlined in the section below on health service delivery, local and internationalNGOs are responsible for the delivery of the basic package of health services(BPHS) in much of the country through the mechanism of contracting out. EPI is aservice in the package and so NGOs have a contractual responsibility to provide it.However, one of the key tools used to assess performance in delivering the BPHS,the balanced scorecard, does not have EPI as an indicator of quality.

Contracts for delivering basic health care mention the need to ‘support’ NIDs. Thisterm ‘support’ is interpreted differently by different NGOs, from doing nothing tocoordination and/or providing vehicles and vaccinators based in their health centres.According to many people met during this evaluation, especially in the EasternRegion, providing static health centre vaccinators for NIDs is distracting from routineprovision of EPI. Where there are no vaccinators in a health facility (e.g. sub-centre)or they are absent, there seems to be some confusion about the role that nurses canplay in immunization. Some managers think that nurses cannot give vaccines, oraland/or injection. This is a misconception that is resulting in lost opportunities.

There also seems to be some confusionabout the role of health posts andcommunity health workers (CHWs) in

routine EPI and SIAs. While the BPHSstates that EPI should be delivered byhealth posts this is interpreted by someas meaning that health posts shouldhelp with the delivery of EPI throughoutreach and mobile health servicesfrom basic health centres. Also, somesee CHWs as being overwhelmed bytasks other than SIAs and do not involvethem even for community mobilisation.The MoPH needs to clarify the role andresponsibilities of basic health facilities,health personnel and other stakeholders

in routine EPI and SIAs.

There are some districts where the delivery of BPHS and more specifically routineEPI and NIDs is not possible because of on-going insecurity. In some places such asHelmand province, private practitioners tend to remain in place, sometimes with theirown pharmacies. Some are already involved in AFP surveillance. They could becontracted to provide EPI on a results basis. Ideally, they should also be contracted,perhaps through something like a voucher scheme, to provide other services such asthe integrated management of childhood illness and antenatal, delivery, and newborncare. At present, such services are not affordable by the poor or they go into debt inorder to pay. Supervision is a challenge but risks have to be taken if EPI and otherservices are to reach those in conflict affected areas.

Management style and practices - A key factor affecting performance is that themanagement of the PEI in some provinces has tended to adhere to one prescribedway of going about things. There has to be a change from such a culture as thereality is that in those areas affected by conflict, where there are the highest numbersof polio cases, the context varies district by district, community by community. Forexample, the acceptability of female vaccinators and female mobilisers can varygreatly within a relatively narrow geographic area.

There is no ‘one best way’ to manage the final phase of polio eradication. Thereneeds to be much more flexibility combined with management risk-taking. Local levelstakeholder analysis and negotiation needs to happen and practices adapted

Mobile health team supported by BRAC

Nimroz Province




accordingly. This calls for local leadership in determining approaches, in negotiation,and in managing personnel. Such leadership exists (although variable, particularly inthe South; a challenge is to recognise and make the best use of it. In this wayappropriate management action will be taken at the local level to address areas ofneed as defined by epidemiological, administrative, communication, and securitydata compiled at provincial and national levels.

Human resource management

There are a number of personnel management factors affecting performance. Theserange from fear and low morale among polio and other health workers to theattitudes about polio among middle level health managers, and from the supervisionof NIDs and routine EPI to the recruitment of volunteers and payment of per diems.

Health personnel in conflict-affected provinces/districts have good reasons to befearful. Insurgents often target them and their health facilities. ISAF forces have hitfacilities and personnel with bombs or sniper fire by mistake. Health facilities havebeen taken over by insurgents, ISAF or the Afghan military. Communities maydistrust health personnel for many reasons. Management of such fear is not easy. Itneeds a mix of approaches that help build trust between different stakeholders.

Some middle level health managers (not directly involved in the PEI), particularlydoctors, are voicing scepticism about the need for such a high focus of attention onpolio. They have never seen a polio case, have higher priorities, and resent theresources being spent on SIAs. They are therefore not supportive of the program.Such attitudes need to be better managed by MoPH and WHO, perhaps throughregular well disseminated statements about the evidence for, and benefits of,continuing efforts towards polio eradication.

Experience in recent months in Helmand province has shown that better negotiationat the local level has allowed SNIDs in previously unreached communities includingsupervision by district personnel. Otherwise, there has been minimal supervision ofroutine EPI and other BPHS services in Helmand by provincial and central levelssince 2004. This has impacted on an ability to validate that activities were conducted

and assess their quality, and on the management of morale.The challenges associated with supervision also play their role in the recruitment ofvolunteers and the payment of their per diems. Recruitment was variously describedas haphazard, inefficient, and inappropriate for the prevailing culture. This is probablya reflection of the fact that so many SIAs are being undertaken with subsequent lossof management oversight. Finally, questions have been raised as to whether peoplebeing recruited for SIAs in some places are really those who could best contribute.The per diem is non-competitive with even the most basic of locally available day jobs, so SIAs do not always attract the best personnel.

Health service delivery in Afghanistan

Afghanistan developed its BPHS during 2002/3 and the third edition is currentlybeing finalised. A complementary essential package of hospital services (EPHS) was

developed in 2005. The main objective of the BPHS is to set priorities in healthservice delivery at each of the five levels of sub-provincial health facilities i.e. healthpost, sub-centre, basic health centre, comprehensive health centre, and districthospital. The services in the package are intended to have the greatest impact onmortality and morbidity. They address maternal and newborn health, child health andimmunization, public nutrition, communicable diseases, mental health, disability andthe supply of essential drugs. For child health and immunization the directive hasalways been to ensure the integrated management of childhood illness and thedelivery of the EPI through routine, outreach and mobile services. In line with the




2004 Constitution, Afghan health policies since 2005 have stated that immunization,among other activities in the BPHS, must be free to any citizen of Afghanistan.

Three donors fund implementation of theBPHS -- the World Bank, the EuropeanCommission (EC), and USAID.Implementation is nationwide through eitherthe contracting out of basic health servicesto NGOs in about 80% of the country, orthrough government run services, the MoPHstrengthening mechanism (MoPH-SM).Progress is being monitored through annualhealth service performance assessmentsand the use of a balanced scorecard.

Overall, many stakeholders see the BPHSand its implementation as a success story.However, challenges in the access to andquality of services are also acknowledged.Specific to polio eradication, these include:

Access – Political, security, cultural and geographical factors are all playing a role inaffecting access by children to both routine EPI and SIAs. In insecure districts andprovinces, particularly in the south of the country, the link between the governmentand the polio program is having a negative impact on access to routine EPI andduring SIAs. Anything to do with government, particularly successful, is deemedworth targeting by the Taliban. Two polio workers were killed a couple of years ago inKandahar province and in Helmand province the NGO implementing BPHS lost 12staff between 2006 and 2008 due to insurgencies and/or targeting. Even fingermarking as proof of polio vaccination can be interpreted by insurgents as havingassociated with the ‘enemy’.

It is well known that civilians suffer from both direct and indirect consequences of

conflict. One of the indirect results is lack of access to health services. In Helmandprovince in 2007 there was thought to be no delivery of the BPHS in at least 50% ofdistricts. Staff had fled for safer locations. Towards the end of 2008, about 90,000children in three districts were not vaccinated against polio as the violence meantthat routine EPI from fixed sites or through outreach or mobile services was notpossible nor were SIAs. The situation has improved recently due to a mix of factors,such as (1) the ability of ISAF to now stay in those geographical areas that they freefrom Taliban control and (2) health and other personnel negotiate more effectivelywith the Taliban and/or community shura (traditional committees).

While geographical access has vastly improved since 2002, there are still someremote areas of the country where it can be 20 or more kilometres to the nearesthealth facility, such as was observed for polio cases in Southern region during 2008-09 (Chapter 1). And in winter, a health facility can be relatively close by but snow and

ice make it inaccessible.




Access to women and their children is a keycultural factor, especially in the conservativesouth of the country. Some communities will notallow women, even if wearing the burquah, tosee, or be seen by a male stranger. So, if thelatter is a vaccinator knocking on the door

during an immunization day, access to a childinside will be denied. On the other hand, wherethere are only males staffing a health post orcentre, women may well not attend for routineEPI. In addition, a newborn child is sometimesnot seen by a stranger or named for the first 40days of its life.

All these factors affect access to routine EPIwhether provided in a health facility or throughoutreach or mobile services but also accessduring SIAs.

Quality – Factors affecting the quality of the EPI and SIAs include fear, fatigue,insufficient resources, and lack of -- or insufficient -- supervision and monitoring andevaluation. Living and working with fear is known to be affecting the quality ofservice delivery. Consultations may be rushed, services not provided at all for daysand weeks, the contractual responsibility of NGOs to ‘support’ SIAs may beneglected or ignored, and there may be inadequate continuing education or trainingin seriously affected conflict areas.

Fatigue - Polio eradication fatigue affecting quality can be of at least four types. First,the fatigue associated with the on-going conflict and the difficulties of trying to deliverquality EPI and SIAs in dangerous environments. Second, the fatigue from too manyvertical SIAs resulting in poor quality commitment and implementation of work,especially as the monetary incentives have risen very little over the past ten years.

Additionally, the high priority given to SIAs has overridden the routine delivery of EPIservices. Vaccinators in static health centres, for example, are being taken awayfrom their routine work and could be spending about 15 days working on each SIA,seriously affecting the quality of EPI delivery.

A third cause of fatigue is associated with the proliferation of vertical donor initiativesdirectly or indirectly impacting on immunization. These include sustainable outreachservices (SOS), reach every district (RED) and quick impact projects (QIPs). Finally,there is fatigue among some communities at having so many interventions toeradicate polio, particularly when many parents do not understand the need formultiple doses, when polio is a rare disease and vaccination is not viewed as apriority for communities.

To counter this it may be useful to consider add-ons to sub-NIDs, providing health or

non-health goods seen as important by a community. Currently, vitamin A is alsoprovided during many SIAs. While this is an important public health measure it is notsomething that communities perceive as important. Notice has to be taken of whateach community expresses as its priorities. These could be provided in Helmandprovince through the quick impact project (QIP) scheme implemented by theprovincial reconstruction team (PRT) and through the potential USAID QIP programfor provinces in the south affected by conflict.

Lack of resources - Some basic health centres and sub-centres even in stableareas do not have adequate resources to ensure the maintenance of the cold chain.

Young women in a courtyard inJalalabad




In conflict affected areas, resources are often available but not in the right place atthe right time because of difficulties in transporting supplies through front lines. Thisis affecting service quality.

The quality of the referral system for the treatment of cases of paralysis is weak.Staff either do not know where to refer cases e.g. to special ICRC centres or that thereferral costs will be covered by the ICRC, therefore the referral is not taken up bythe family because of the (hidden) costs involved. In addition, there are alsoinadequate resources at both district and health centre levels to provide rehabilitationservices, despite disability being part of the BPHS. Moreover, most provincialhospitals lack physiotherapy capacity to provide these services.

Supervision and monitoring - The systems and capacity to supervise and tomonitor and evaluate the quality of BPHS implementation and more specificallyroutine EPI and SIAs are in place. The problem is that in conflict affected districtsthey are not being used. For example, the balanced score card, one of the tools toevaluate the contracting out and in of health services, has not been used in Helmandand Kandahar since 2004. MoPH Kabul and provincial level staff are too afraid, orsometimes not allowed to travel to or within the provinces. In addition, the card lacksan indicator judging the quality of the EPI. This is a major omission.

Summary

During the post conflict period (2002-2004) Afghanistan put in place a sound healthdevelopment framework. However, since 2005, progress in health has been slowingor has stalled in a number of districts and provinces. Both the health system andhealth services are currently functioning in a challenging context dominated byincreasing insecurity and complex politics and power processes. The key healthsystem and service delivery barriers to polio eradication are all to do with theapproach to work and its management in such a complex context. As discussed inChapter 2, there is sound technical analysis, implementation and surveillance.People know ‘what’ to do -- the challenge is ‘how’ to go about the work, especially inthose areas of the country where insurgents are killing or intimidating peopleincluding health personnel.




CHAPTER 4: COMMUNITY ISSUES AFFECTING PROGRAM PERFORMANCE

Communities as partners – The eradication program has a wealth of experienceover the past few years of working at the community level. But it would seem thatthere has been insufficient analysis or discussion as to whether the ways of workingin peaceful areas have relevance to areas where there is insecurity or conflict. In thesub-section on management style and practices in Chapter 3 there is mention thatthe management of the PEI has tended to adhere to one prescribed way of goingabout things. A reality is that in peaceful areas there may well be little genuineworking ‘with’ communities. NIDs are frequently done by outsiders with something ofa top-down approach. However, the complexities of delivering vaccines in times ofinsecurity necessitate a change.

There is no one ‘right way’ to engage with communities in security-compromisedareas. But experience in Helmand province in the provision of water supplies andmore recently in immunization is showing that constructive dialogue, listening andresponding to community needs, priorities and cultural values and the developmentof trust are playing a key role. When communities are made to feel they are genuinepartners, that their views are listened to, they are prepared to consider options toallow key interventions to be implemented. In each locality, it is important to involve

both men and women in ways that reflect their local status and decision-makingroles.

Men in the community are critical to enabling participation by women in SIAs. Noman, whatever his political or tribal affiliation, wants to see his children or women illor die. Compared with the rest of the country, communities in the south tend to bequite conservative. Men are usually the local intermediaries and they are crucial forthe necessary dialogue with mullahs, elders or some other respected member(s) ofsociety, no matter what political or other affiliation. The PEI has quite rightly workedwith male mullahs and elders to mobilise community engagement. However, greaterefforts should be made to convince male heads of households to enable access byvaccinators to their women and children. It is important to engage men while theirwives are pregnant to ensure that they understand the importance of the birth dose

of OPV so that they encourage women to take their newborn infants to health centresand to allow access in the home to newborns during SIAs.

Elderly women and mothers-in- law in the home also play a critical role in householddecision making. It is therefore important to bring women into the communicationloop in addition to targeting individual men and community shura. In somecommunities there may well be a respected woman - sometimes because of thestatus of her husband - who is allowed to go from house to house. This is thought tobe the case of the wives of barbers in Helmand province but maybe not be the casein Kandahar. Having female volunteer vaccinators is acceptable in some areas of thecountry (e.g. Jalalabad) but not others (e.g. Khost).

Earlier, the value of listening and responding to community needs and priorities wasmentioned. Demand for polio vaccination may well be non-existent because people

may not have seen a case for years. Communities usually have other priorities,sometimes in the health sector, sometimes not. It may be useful therefore to providean add-on to any sub-NID, something that responds to a stated priority. Again, this isgoing to vary from community to community and between SIAs in any onecommunity. But add-ons could range from bed nets (for the biting nuisance ofmosquitoes in areas where there is no malaria) to high-energy nutritious biscuits,from vaccination for animal diseases to improvement in water supplies. Asmentioned in chapter 3, the Helmand PRT has funds from a QIP that could be spenton such add-ons. There may be something similar in Kandahar province. USAID isplanning and hoping to have a QIP for all southern provinces affected by insecurity.




Undertaking immunization at the community level

Planning for SIAs has to be done community by community to respond to localpriorities, socio-cultural factors, and attitudes and beliefs about vaccination. In thisway approaches to community mobilization for routine EPI and SIAs will beappropriate as will the role of women as vaccinators. Communities may well feel thatthey are being listened to with trust gradually developed on both sides. This can onlybe beneficial to the program.

The selection of volunteer vaccinators andof post-campaign monitors seems to besomewhat ad hoc. With so many NIDs andsub-NIDs, attention to detail can only besuffering. This selection is the responsibilityof district coordinators, coordinatingcommittees, and cluster supervisors. Wewere informed that in security-compromisedareas, provincial PEI staff are unable to visitthese districts and villages to verify thequality of performance of these community-

level personnel.

For routine and/or sub-NIDs, bridging into non-secure areas could be via otheractors. Mention was made in chapter 3 of using private practitioners. In communitiesthe health of livestock is often a top priority. Where there is an animal healthprogram, the links could be made with veterinary workers to combine activities,improving access and developing a cost-efficient approach. This is further developedin Chapter 5.

Post-campaign monitoring surveys consistently find low rates of refusals (2-3% ofmissed children during 2009); however, there continue to be high rates of absentchildren (40-50%) and missed newborns (20-30%). Some believe that these lattertwo categories may represent “silent refusals”; so more operational research iswarranted on this issue.

Summary

The community level, including the pivotal role of certain men and older women, isthe key to the successful eradication of polio in Afghanistan. In the (deteriorating)conflict context, it is only at the very local level that the means for immunization,supervision, surveillance and monitoring and evaluation can be negotiated and bemade to happen. Individual men, such as village notables, elders, mullah, teachers,and CHWs, village ‘khala’ or midwives, and community shura often have the powerto provide the humanitarian space necessary to deliver essential services. Tosuccessfully work with communities, they need to be considered as genuinepartners, no matter what political or tribal affiliations may be held by individualmembers. And trust must be a core value, enabling successful implementation ininsecure areas of the country.

Female vaccinator durin SIA




CHAPTER 5: NON-HEALTH FACTORS AFFECTING PROGRAMPERFORMANCE

Security situation

Insecurity poses the most significant barrier to achieving high polio vaccinationcoverage throughout the country. The security situation is unstable, unpredictable,

and threatened by a range of armed factions. The UN Department of Safety andSecurity (UNDSS) reported an increase in security incidents nationally from just over600 in January 2009 to more than 1100 in June. Currently, the most security-compromised districts are in the southern provinces of Helmand, Kandahar,Urozgan, and Nimroz provinces and the western province of Farah, where insurgentforces are active.

Security in previously stableareas has recently deteriorateddue to insurgency, for example,in Kundoz province (NE), Kapisaand Worduk provinces (Central),Nuristan province, especially

Barge Matal District (East), andPaktia and Ghazni provinces(SE). In the western province ofHerat, insecurity is due to a mixof insurgency and criminality. Allcases of polio reported since2006 have occurred in theprovinces marked red, orange,or yellow in the UN security mapof August 2009.

Anti-government elements (AGE) do not comprise a homogeneous force under a

single central command. Violence affecting access by vaccination teams to certainareas may be due to local tribal factions, organized criminals, and Taliban insurgentsloyal to Mullah Omar. Some of these factions have been alienated by policies of localpatronage. The letter of support for the polio eradication program issued by theQuetta Shura has been helpful in gaining access to certain insecure areas but noteffective in other areas where additional negotiation is required with local AGEcommanders.

Insecurity in the NWFP and Federally Administered Tribal Areas of Pakistan is alsoimpacting on the PEI in eastern and SE Afghanistan. Inability to maintain high levelsof vaccine coverage and effective AFP surveillance in these areas poses a threat ofimported WPV, exacerbated by the movement into Afghanistan of people displacedby the conflict in Pakistan.

Inaccessible districts and proportion of target children inaccessibleWhile some districts in some other provinces are inaccessible during some SIAs, thesouthern region continues to suffer the most consistent security barriers. During the12 SIAs between January 2008 and April 2009, six districts were inaccessible duringnine or more rounds, seven during between five and eight rounds, and a further 16between 1-4 rounds. Overall, around 17% of children were missed during thisperiod. Post-campaign assessments have consistently found OPV coverage to bearound 70% in SIAs in the southern region.




Nevertheless, there has been some improvement since April 2009. The proportion ofchildren living in inaccessible areas of the South declined from 16% in May to lessthan 5% in July. Post-campaign assessed OPV coverage increased from 70% inMarch to 78% in June. Although the proportion of monitored clusters reporting OPVcoverage greater than 95% following SIAs in the South increased from 25% in Aprilto 32% in June, the proportion with coverage less than 90% remained static at 52%,

indicating that certain areas remain firmly inaccessible.

Examples of AGE-controlled districts where access has been achieved

Musa Qala and Nauzad districts ofHelmand province (both high-risk) hadbeen inaccessible since early 2008;however, local non-health sectornegotiators have been able to ensure100% access in the May and Junecampaigns. In AGE-controlled Nadealidistrict, which was inaccessible untilMay 2009, the NGO IbnSina,responsible for delivery of the BPHS in

Helmand, was able to access thepopulation in June through placingtransit teams at the Lashkargah bridge.

Similarly, the NGO Bakhtar Development Network was able to negotiate access toNawa District in Ghazni province in July after having been missed for 11 months.Other examples were provided to us from Eastern, SE and SW provinces of effectivelow-level negotiation to access high-risk areas through elders, mullahs, and localTaliban commanders. In one district of Herat, the Taliban commander reported backon the outcome of the campaign. In the highly insecure district of Bakwa in Farahprovince, separate negotiations have to be conducted with 14 different tribal groupsto achieve access.

Implications of recent military policy changes

In 2009, a change in NATO/ISAF policy has seen a shift away from “pursuing theenemy” to “stabilising” populations and enabling the delivery of essential services.Military offensives will only target areas where it is feasible to maintain ongoingcontrol. This policy shift is apparently mirrored by recent directives from the QuettaShura to Taliban commanders; thus setting up a major battle to “win the hearts andminds of the people”.

This policy shift poses both significant opportunities and threats for the PEI. Theopportunities consist of potentially sympathetic attitudes by local militarycommanders to requests for access and the temporary cessation of hostilities. Thethreats include (1) the potential direct delivery of vaccination and other healthservices by military forces and (2) combatants on both sides taking credit publicly forcampaign achievements. For example, we were informed that in Bakwa district of

Farah province, health facilities were being variously managed by ISAF, AfghanDefence Force, and Taliban personnel. Such a scenario might be repeated in BargeMatal district of Nuristan, which ISAF forces have recently occupied but Talibanforces continue to control access roads and service providers cannot enter.

On a positive note, we were re-assured by senior NATO/ISAF commanders that itwas not their intention to directly deliver health services thereby risking alienatingcommunities hostile to the Afghan Government and foreign military forces. A draftmanual of Standard Operating Procedures (SOPs) for the support of social servicesin stabilised populations has been developed by NATO. However, it has not been




finalised and its contents have not yet been widely disseminated in the field. Weheard expressions of frustration by some ISAF commanders that if service providerswere not available in a newly stabilised area “…how could I prevent my soldiers fromstepping in and saving lives?”

Impact of high-profile endorsement of campaigns

It is legitimate to commend the strong endorsement of the PEI by the President,ministers, governors, and other political figures. We saw extensive evidence of ahigh level of community awareness and acceptance of polio vaccination. We wererepeatedly told that negative attitudes towards vaccination and refusals were veryrare. This must in part be attributed to the high level of political commitment.

However, we were also informed on many occasions, especially in the eastern andsouthern provinces that this high-profile endorsement of SIAs by politicians alignedwith the Government of Afghanistan may be counter-productive in security-compromised areas.

We were told that the Taliban will oppose any program that they perceive to beimportant to the government. Thus, while continued commitment to the program atthe highest level of government is important to ensure allocation of essentialresources, it may now be timely to express that commitment privately.

Moreover, it is equally important that military officers, both Afghan and ISAF, notmake public statements about the PEI that may lead the Taliban to oppose it merelybecause it is perceived to be a military priority. Some foreign governments have bothmilitary forces and aid programs in Afghanistan, some of which support the PEI. Thisraises the possibility that in areas controlled or influenced by anti-governmentelements, immunization activities may be perceived by community leaders to beintertwined with military operations. The neutrality of the polio program must beprotected.

UN agency representatives should be cautious about publicly endorsing or takingcredit for a program whose success could be perceived as one important element in

maintaining popular support for the government. The planned linkage of theSeptember SNID with UN Peace Day should be an internal matter only. Publiclylinking the two events may further promote the perception that United Nations andGovernment of Afghanistan agendas are identical.

Population mobility

The transmission of WPV inAfghanistan is directly linked tocirculation of WPV in Pakistan.There are two transmission corridorsbetween the countries – Kandahar-Sindh and Eastern Region-Peshawar Valley (NWFP). Very

high numbers of people cross thePakistan-Afghanistan border in eachdirection for economic, social, andsecurity reasons. For example,each day an average of 15,000people cross the six border pointsbetween Nangahar and NWFP.

Most of this movement is for social and economic reasons and continues a longtradition of cross-border movement. In addition, a surge of violence in NWFP's

Torkham border ost




Swat, Buner and Lower Dir districts in 2009 forced more than 2 million people to fleetheir homes, some of whom may have entered Afghanistan. It is difficult to estimatethe number of “true” refugees fleeing Pakistan’s violence because they cannot bedifferentiated from Afghan refugees returning after spending many years in Pakistan.We were told that 146 families from Balochistan recently arrived in Kabul, amongwhom 240 children were vaccinated with OPV.

There are an estimated 270,000 internally displaced persons within Afghanistan;most have fled violence in the southern region of the country where WPV iscirculating and OPV coverage rates are low. In addition, UNHCR estimates that since2005, up to 50,000 refugee returnees have remained unable to return to areas oforigin due to security constraints, and have sought shelter in spontaneous camps ineastern Afghanistan.

Role of Afghan Army and Police

As the key organs of maintaining peace and security, the Afghan Defence Force andPolice can play an important role in ensuring an enabling environment to conductvaccination campaigns. While awareness of PEI is high at the central level throughinter-ministerial committees, we heard numerous stories of suspicion and obstruction

at the local level. In areas that are only marginally secure, the movement ofvaccinators from house to house has been misinterpreted in some areas, especiallyby the police. We heard that this has been particularly the case when femalevaccinators move around in areas where the perpetrators of security threats havebeen disguised in burquas.

Potential role of integrating campaigns with animal health vaccination

The final stage of the PEI in Afghanistan could benefit from collaboration withpartners whose programs share many of the same challenges but who also havenetworks that could complement the efforts being made to vaccinate children in hard-to-reach communities.

There are approximately 625 Veterinary Field Units (VFU) nationwide. Currently, theMinistry of Agriculture maintains 150 of these units but will soon hand over 120 to theprivate sector. After this handover, more than 200 VFUs will be managed by theAfghanistan Veterinary Association (AVA), which has seven regional offices,including Kandahar, Nangahar, and Herat. We were informed that the AVA has alarge number of members in the southern and eastern provinces.

A VFU is a small veterinary office orclinic located in a district to provideanimal health care services to thefarmers and animals of the nearbyvillages. VFU staff providevaccination, de-worming, medicaland surgical treatments to the districtanimals – at the VFU and in the

field. They are also responsible forsurveillance of animal diseases andtrain community-based BasicVeterinary Workers (BVW). TheMinistry of Agriculture estimates that40% of villages in the country haveBVWs.

Vaccination of cattle againsthaemorrhagic septicaemia




Vaccines against a wide range of animal diseases are procured by the AVA or theDutch Committee for Afghanistan and maintained in a parallel cold chain down to thelevel of the VFU.

The similarities between the animal health program and the PEI are illustrated by amassive animal vaccination campaign undertaken during the summer in Badakhshanaiming to vaccinate millions of sheep, goats and other livestock brought to summerpastures in the Sheva Valley. This campaign required the mobilization ofcommunities through village shura and the participation of numerous VHU staff,BVWs, and community mobilisers. Given the high priority accorded by ruralcommunities to animal health and the extensive network of experienced district- andvillage-based vaccinators and volunteers, it may be useful to explore closercollaboration between the PEI and the animal vaccination program.

One example of how animal vaccination networks have been used to help achievehigh coverage in NIDs is in Chad. This experience was described in a paper3, whoseconclusions were as follows:

Schelling E, Bechir M, Ahmed MA, Wyss K, Randolph TF, Zinsstag J. Human and animal vaccinationdelivery to remote nomadic families, Chad. Emerg Infect Dis. 2007 Mar;13(3):373-9.

Sustained vaccination programs are essential tools for both the public health and

veterinary sectors. Combined human and livestock vaccination reducesoperational costs of interventions requiring costly transportation and is adapted tolivestock holders who highly value the approach that considers the health both ofthe family and of the animals that contribute importantly to their livelihood. InChad, a common policy agreement between the two sectors on cooperation inrural zones should define a cost-sharing scheme. By optimizing the use of limitedlogistical and human resources, public health and veterinary services will bestrengthened, especially at the district level, and, in turn, will be more preparedand operational in responding to endemic and epidemic diseases.




CHAPTER 6. TECHNICAL ISSUES THAT MAY BE BARRIERS TOERADICATION

Frequency and flexibility of SIAs

Less frequent but higher quality national campaigns could ensure greater coverageand minimize adverse impacts on routine EPI and other basic health services.

Flexibility with the timing of sub-national immunisation days could improve micro-planning and negotiating access to populations in insecure areas including for post-campaign assessments.

A rigorous, technical assessment of the minimum number of NIDs necessary toensure sufficient immunity among the target age group is required before anyreduction can be recommended. The analysis could consist of modelling likelyimmunity in each province, based on routine EPI coverage, SIA access andcoverage, and exposure to migration from areas where WPV is circulating. (The roleof NIDs in strengthening AFP surveillance should not be forgotten.) A similar analysiscould be conducted for SNIDs considering needs at provincial, district or even sub-district levels. The current gap analysis used to classify high-risk areas appears to bea comprehensive tool but could perhaps also include under-five nutritional status andaccess to clean water and sanitation.

Maintenance of high quality AFP surveillance and continued efforts to improveroutine EPI are essential.

Confirmed cases of polio in children with more OPV doses than recommended

Since 2006, 43% of children with polio reportedly received 5 or more doses of OPV;22% had received over 10 doses. For any vaccine with less than 100% efficacy, it iscommon that an increasing proportion of cases will be observed among vaccinatedchildren as coverage increases and disease incidence declines. Nonetheless, abetter understanding of the reason(s) why these children still developed paralyticpolio could identify potentially modifiable factors.

Previous assessments of the cold chain have not revealed any major problems and it

is unlikely that multiple batches of the vaccine were non-viable. On the other hand,validation of doses given is problematic in Afghanistan when only a minority offamilies retains their immunization cards for documentation of routine EPI antigensand parents consistently over-report doses received during SIAs.

Individual factors interfering with immunity may be important in Afghanistan. Forinstance, high circulation of non-polio enteroviruses has been cited as an impedimentto developing protective immunity after vaccination in several states in India. Therelatively high proportion of enteroviruses isolated in specimens from some provinceslends support to this theory. More tenuously, the listing of Guillian Barre syndrome asthe most common cause of non-polio AFP in most regions could suggest thepresence of enteric organisms (and/or respiratory pathogens) that could causediarrhoea and interfere with immunizations. We did not review population nutritionaldata but malnutrition may also play a role in poor immune responses to vaccination

in several settings. In some individuals, primary immunodeficiencies may explainparalytic polio despite many OPV doses, but cases are nonetheless sentinelindications of circulating wild virus.

Investigations of cases could go further in attempting to elucidate pertinent factors,particularly for cases occurring outside the Southern endemic area of transmissionand will become more important as the number of annual cases declines.




Possibility of transmission of WPV by infected adults with diminishedimmunity

Epidemiological investigations into the polio cases detected in Central region (Kapisaprovince) and Eastern region (Nuristan province) in 2009 found that the onlypertinent contact was with young adults who had recently returned from Pakistan.While no cases of polio have been seen in older age groups in Afghanistan, sporadic

cases in countries free of wild polio virus have shown the potential role of youngadults in the spread of polio. For example, a young student from Pakistan wasdiagnosed with polio in Australia after returning from a vacation in his own country. Inthe absence of rapidly ensuring high coverage with OPV of each new birth cohort inAfghanistan and Pakistan, consideration could be given to investigating the role ofinfected young adults and identification of appropriate responses if required. Forinstance, compulsory travel vaccinations are standard for travel to some parts of theworld and Saudia Arabia insists on OPV for all arrivals regardless of age. Other GulfStates are investigating the feasibility of following this course under the newinternational health regulations. Any recommendations would need to ensure that thecurrent polio program in Afghanistan was not adversely affected by the introductionof new measures targeting older age groups.

Specificity and sensitivity of AFP surveillance and future review of“inadequate” AFP cases by ERC once incidence of confirmed polio casesdeclines to near zero

The quality of inclusion and exclusion of AFP cases throughout Afghanistan variesand stakeholders called for additional training of provincial focal points by the ERC.(Some stakeholders indicated that more female paediatricians would improve thequality of information collected on female cases.) Falsely excluding AFP caseswithout adequate examination was felt by the 2008 surveillance review team to bemore of an issue than erroneous inclusions. So while the system may be sensitive inthe first instance – through employment of a loose case definition and provision ofincentives to reporters – cases of AFP may be missed through misclassificationduring the initial case investigation.

As case numbers decline with improved immunization coverage, the quality of thereview of inadequate cases may need to be increased. For example, this could beachieved by ensuring in-person review by members of the ERC, and/orstrengthening the capacity of AFP focal points to collect sufficient clinical informationfor the ERC to make a firm diagnosis (e.g. videos of clinical examinations; access tomedical investigations and imaging) and to follow-up cases for the requisite period.

Although the reasons why cases were ‘inadequate’ are routinely reviewed within thecurrent system, this practice may also need to be improved. In particular, lessonslearned from individual cases about how to improve early detection should be sharedwith all surveillance system stakeholders.

High male: female ratio of reported AFP cases

For most provinces in Afghanistan more boys than girls are reported to the AFPsurveillance system. The reason(s) why are not clear but may include reportingbiases due to gender differences in health seeking behaviours, differential exposuresdue to the behaviour of boys and restrictions on movements of girls, different natureof medical treatment offered (e.g. injections causing traumatic neuritis) and differentrates of primary immunodeficiencies (which in many settings more commonly affectmales). Identification of relevant factors could improve the quality of surveillance andpossibly even lead to interventions to reduce AFP cases.




Sensitivity of surveillance of vaccine-associated paralysis

Data collection from AFP cases allows a retrospective assessment of probable casesof VAPP. This could be compared with an assessment of the expected number ofcases for the number of doses delivered annually. If older age groups were targetedfor OPV then this process of review may need to be conducted more regularly.




CONCLUSIONS

1. The PEI has achieved remarkable success in an increasingly challengingenvironment. For the majority of the Afghan population (84%), ongoing poliotransmission has ceased. Indeed, the range of wild polio virus has reduced fromsix of seven regions in 2000 to four regions in 2009, and 80-90% of all confirmed

cases reported annually since 2006 have been from the Southern region. Ofthese, three-quarters were detected in just 10 insecure districts within the region(Dihrawud, Kandahar, Maywand, Nad Ali, Panjwayi, Sangin, Shah Wali Kot, SpinBoldak, Tirin Kot, Musa Qala).

2. There is a very high level of political commitment, coordination by partners, andtechnical quality of PEI team work. The high level of planning, review, andanalysis of SIAs is impressive. There is regular coordination with the PEI inPakistan.

3. The high quality and coverage of AFP surveillance is being maintained, even insecurity-compromised areas. An independent evaluation in 2008 found that it ishighly unlikely that any polio cases are not being reported in four of the seven

regions. Active surveillance in some regions (Western, Central) has declined in2009 compared to previous years. Surveillance links with the border areas ofPakistan are weak and recommendations to strengthen links with central Asianstates have not yet been implemented. It is unclear if the system could detectcases of polio in older children or young adults.

4. Despite the contraction of the area of polio transmission, the annual number ofconfirmed polio cases is not diminishing and appears to have remained static forthe last four years, with 18 cases reported during 2009 up until mid-August,consistent with the reported incidence in 2008. There is a relatively low routinecoverage of OPV3/OPV4 nationally, although this is difficult to estimate by theadministrative method because target figures are based on inaccurate populationstatistics.

5. Since 2007, security has been deteriorating in many previously stable provinces(eg, Kapisa, Paktia, Kundoz, and Ghazni). The shared border with insecure areasof Pakistan, such as Kurram, Bajaur, North and South Waziristan, wherevaccination and AFP surveillance may be sub-optimal poses a major threat ofimportation into eastern and southern provinces.

6. The main health system and health service barriers to achieving polioeradication include the following factors:

• Significant disruption of routine EPI services by the high number of SIAs.This was highlighted particularly during discussions with health staff in theeastern and southern provinces, where there are almost monthly NIDs and

SNIDs and where vaccinators from fixed facilities are mobilised for SIAs.• Health facilities, especially sub-centres are often inadequately resourced to

provide routine EPI services.

• Inconsistent understanding of responsibilities of sub-centre health staff; insome provinces, nurses and midwives are not expected to provide EPI in theabsence of designated vaccinators.

• In a number of southern, south-eastern, and eastern provinces there is aninability to conduct adequate supervision, M&E, and data validation. This is




due to a combination of inability to access insecure areas and a lack oftrained supervisory staff.

• Inadequate EPI outreach and mobile teams as well as a confusing number ofdonor initiatives (eg, SOS, RED, Quick Impact, IMCPN).

• The replacement of the NGO responsible for BPHS in Helmand Province,

IbnSina, which has many years of experience working in a conflict-affectedenvironment, by an international NGO may have a negative impact on futureSIAs.

• Private practitioners are not adequately involved in the provision of routineEPI services, especially those who continue to work in insecure areas.

• There is not a functional referral system for polio and other AFP cases toeffective rehabilitation services, such as those provided by the ICRC.

• The Balanced Scorecard for monitoring BPHS lacks an indicator for EPIservice delivery.

7. The main community barriers to achieving polio eradication include thefollowing:

• A certain lack of flexibility in accessing children safely. There is no one “rightway” to engage with communities in security-compromised areas, while thereare a number of examples of negotiation through different localintermediaries, including NGO district staff, hired negotiators, mullahs, andtribal elders.

• Bridging into non-secure areas could be via a broader range of actors, eg,private practitioners and veterinary workers.

• In some areas, men may need to be the greater focus of communitymobilisation to enable access to women and their children (especiallynewborns) and to allow women to move around as mobilisers and/orvaccinators.

• Recruitment of volunteers for SIAs was variously described as haphazard,inefficient, inappropriate for the prevailing culture and a means for friends toearn money. This is probably a reflection of the fact that so many SIAs arebeing undertaken with subsequent loss of management efficiency.

• The selection of volunteer vaccinators needs to reflect cultural and politicalrealities, e.g. female vaccinators are acceptable in some areas (e.g.Nangahar) but not in others (e.g. Paktia).

• While we found little evidence of resistance to immunization and low refusalrates, demand for polio vaccination is relatively low because it is notperceived by communities to be a high priority. While vitamin A is givencurrently, it might be worth linking polio vaccination with delivery of services

perceived to be of higher priority (e.g. nutrition, bednets, and animalvaccines).

8. The main PEI management barriers to success include the following:

• A key factor affecting performance is that the management of the PEI hastended to adhere to one prescribed way of going about things. There needsto be much more flexibility combined with management risk-taking.

• Issues related to human resource management (e.g., low salaries ofvaccinators and incentives for volunteers) need to be addressed. There is




also a need to manage fatigue associated with the difficulties of trying todeliver quality EPI and SIAs in dangerous environments, the high frequencyof SIAs, and the proliferation of so many vertical donor initiatives directly orindirectly impacting on immunization.

• Some middle level health managers (not directly involved in the PEI),particularly doctors, are voicing scepticism about the need for such a highfocus of attention on polio. They have never seen a polio case, have higherpriorities, and resent the resources being spent on SIAs. They are thereforenot supportive of the program.

• Lack of consistent understanding of roles of NGOs in the implementation ofSIAs. The degree of engagement in SIAs by NGOs implementing the BPHSis highly variable and inconsistent.

9. The main coordination and communication barriers to success include:

• High profile political endorsement of the polio eradication program may nolonger be appropriate and, in some security-compromised provinces, mayhave a negative effect. Anything to do with government, particularlysuccessful, is deemed worth targeting by the Taliban.

• Moreover, it is equally important that military officers, both Afghan and ISAF,not make public statements about the PEI that may lead the Taliban tooppose it merely because it is perceived to be a military priority.

• UN agency representatives should be cautious about publicly endorsing ortaking credit for a program whose success could be perceived as oneimportant element in maintaining popular support for the government.

• Perceived fear by service providers is not always adequately addressed andcould benefit from better information on the actual security situation incontested areas.

• Not all communication strategies may be appropriate in all high-risk areas(e.g., women’s courtyards may not be suitable in rural areas). A broad rangeof strategies appropriate for specific cultural groups (eg, women’s literacyclasses that are being used in Kandahar and Helmand provinces tocommunicate vaccination messages) needs to be further trialled andimplemented.

• Inadequate strategies to address the barriers to communication between allstakeholders (e.g., MOPH, NGOs, UN, ISAF, ICRC, AGE).

10. The main technical barriers to polio eradication include:

• Some polio cases have occurred in children who have received more than 10OPV doses. The recent cases in Nuristan and Kapisa are examples of thisissue.

•

There is evidence that several recent polio cases occurred in children whohad neither travelled to nor been in contact with children from endemic zones.However, they were in contact with older children or young adults who hadreturned from Pakistan (who may have diminished immunity).

• We found a lack of epidemiological evidence to continue the high number ofSIAs in provinces where WPV is not circulating.

• We found a lack of evidence to explain the high male: female ratio of reportedpolio and non-polio AFP cases.




11. The main non-health sector barriers to polio eradication include:

• Insecurity poses the most significant barrier to achieving high poliovaccination coverage throughout the country. The security situation isunstable, unpredictable, and threatened by a range of armed factions.

• Changing policies of ISAF and Taliban, which focus not so much on pursuing

the enemy but stabilising populations and enabling the provision of socialservices. This change offers both opportunities and threats.

– Opportunities to provide access to service providers.

– Risk of direct service provision by combatants, which may be inconsistentwith the basic humanitarian principles of neutrality, impartiality, andindependence.

• The movement of large populations both between Pakistan and Afghanistanand between provinces within the country has the potential to introduce WPVinto areas where it has long been absent. Population migration alsoconstrains local program planning because the size of the target populationduring SIAs may be under-estimated.

• Possible contradiction between military and humanitarian objectives of majordonor governments. A number of governments have both military forces andaid programs, some of which support the PEI. This raises the possibility thatin areas controlled or influenced by anti-government elements, immunizationactivities may be perceived by community leaders to be intertwined withmilitary operations. The neutrality of the polio program must be protected.

• Lack of active involvement of non-health ministries in the field. For example,there is minimal collaboration with the national network of animal health,including 625 veterinary field units and a large number of community-basedbasic veterinary workers. There is a need to communicate the purpose ofimmunization campaigns to all levels of the Afghan military and police.

Internally displaced persons living in Kabul




Annex 1: Persons Met

Government of the Islamic Republic of Afghanistan

Dr. Najibullah Mojadidi, Senior Advisor on Health & Education to thePresident

Ministry of Public Health, Kabul

H.E. Dr. Muhammad Amen Fatimi, Minister of Health

Dr Nadera Hayat Burhani, Deputy Minister, Health Care Services and Promotion

Dr Faizullah Kakar, Deputy Minister of Health, Technical Affairs

Dr Ahmad Shah Salehi, Director Health Economics and Financing Directorate

Dr Mohammad Taufiq Mashal, Director, Preventive Medicine and Primary HealthCare

Dr Agha Gul Dost, Director EPI

Dr. Gula Khan, medical officer

Dr. Nafi, medical officer

Ministry of Agriculture, Kabul

Dr Mohammad Anwar Sadaf, Acting Director General, Livestock and Animal Health

United Nations Assistance Mission in Afghanistan

Mr Kai Eide, UN Special Representative in Afghanistan

World Health Organization, Kabul

Mr. Peter J.Graaff, Country Representative

Dr. Tahir Pervaiz Mir, Polio Medical Officer

Dr. Ali Ahmad Zahid, Polio surveillance

Dr. Rohullah Habib

Mr Mamdouh Samuel

Mr Mohammad Zahid

Mr Haroon, Data analyst

Mr Hamid Pason

UNICEF, Kabul

Ms Catherine Mbengue, Country Representative

Gopal Sharma, Deputy Representative

Ms Savita Naqvi, Chief of Program Communication

Dr Zahra Mohammed, EPI Specialist

Dr. Saboor Bahrami, EPI Officer

Dr. Attai Mohammad, Health Officer, Central Region

Mr.Juma Din, Security Officer




International Security Assistance Force

Rear-Admiral Matthieu Borsboom, Deputy Chief of Staff Stability, Kabul

Brigadier-General Jonathan Vance, Commander, Canadian Forces, Kandahar

Colonel Richard Dixon, Civil-Military Cooperation. RC South

Lt Col Dr Jo Palmer, Health Advisor, RC South, Task Force HelmandWorld Bank, Kabul

Kees Kostermans, Lead Public Health Specialist, South Asia, Washington DC

Tekabe A Belay, Senior Economist (Health), Washington DC

Dr G Sayeed, Public Health Specialist, Kabul Office

International Committee of the Red Cross

Reto Stocker, Head of Delegation

Dr Jose Bastos, Health Coordinator

Office for the Coordination of Humanitarian Affairs

Lucio Melandri, Humanitarian Affairs Officer, Civil-Military Coordination

Canadian Embassy/Canadian International Development Agency

Cindy Termorshuizen, Deputy Head of Mission

Rifah Khan, Second Secretary, Development.

Cindy McAlpine, Kandahar.

Chantal Ruel, Kandahar.

United States Agency for International Development

Tara Milani, Health Development Officer

Bradley Bessire, Director, Office of Social Sector Development

Faiz Mohammad, Health Team Leader

Japanese International Cooperation Agency

Sachiko Goto, Assistant Resident Representative

Afghan Health and Development Services, Kabul

Dr Mohammad Fareed, Deputy Director

Ibn-e-Sina, Kabul

Dr Mirza Jan, Country Director

Dr Faiz Mohammad Atif, Director of Operations

Eastern RegionHE Mohammad Aleem Isehaq Zai, Deputy Governor, Nangahar Province

Dr. Khushal Zaman, WHO medical officer

Prakash Tuladhar, UNICEF Chief of Office Eastern Region

Dr Abdul Wahidi, Health and Nutrition Specialist Eastern Region

Dr. Ajmal Pardis, Nangahar provincial health director




Dr. Hakim Jan, regional polio officer

Dr. Safeer Mohammad, assistant regional polio officer

Dr. Abdul Basir, Nangahar provincial polio officer

Dr. Asad Ullah Fazli, Kunar provincial health director

Dr. Mohammad Sardar, Kunar provincial polio officer

Dr. Wahid Azizi Kunar provincial polio officer

Dr. Latif, Laghman provincial health director

Dr. Shafiq Ullah, provincial polio officer, HealthNet

Dr Attanullah, Aide Medicale Internationale (AMI)

Dr Arsallah, EPI Focal Point, AMI

Dr Abdul Raziq, AMI Kunar

Dr A. Ouyu, Afghan Reconstruction and Development Centre (ARDC)

Dr Safiullah, Medical Supervisor, ARDC

Dr Jaleed Ali, Project Manager, BRAC Afghanistan

Dr Noor Gossan, Medical Coordinator, BRAC

Dr Ezatullah, Hewad

Dr Haznat Ali Hamad, Church World Service – Pakistan/Afghanistan (CWSPA)

Dr M. Daud, International Medical Corps (IMC)

Dr Gul Asquer, IMC

Southern Region

HE Tooryalai Wesa, Kandahar Provincial Governor

Dr. Abdikarim Asseir, PMO, Kandahar

Helene Kadi, Chief UNICEF Field Office, Southern Region

Sardar Popal, Acting Polio Communication Officer, Southern Region

Dr. Javed Iqbal, PMO

Dr. Rahmatullah Kamwak

Dr. Najibullah Zafarzay (RPO)

Dr. Hamidullah (ARPO)

Dr. Mohammad Essa (Kandahar provincial polio officer)

Dr. Abdul Qayoom Pokhla (Kandahar provincial health director)




Haji Nazar Mohammad (REMT)

Dr. Fazal Rahman

Dr. Asif Gul (Nimroz PPO)

Dr. Noor Ahmad Shirzad (Nimroz PHD)

Mr. Sayed Askar Shah (Nimroz PEMT)

Dr. Un-Sul Haq Rahimi (BARAK)

Dr. Abdul Rahman Jawad (Urozgan PPO)

Dr. Khan Agha Maikhil (Urozgan PHD)

Mr. Saif-u-din (Urozgan PEMT)

Dr. Ajab Noor (Zabul AHDS)

Dr. Mohammad Tahir (Zabul PPO)

Dr. Gul Ahmad (Zabul PHD)

Mr. Adam Khan (Zabul PEMT)

Dr. Fazal Rahman (Zabul Ibn Seena)

South Eastern Region

Dr. Shamsher Ali, STC, WHO

DR. Naik Mohammad, RPO WHO

Dr Abdul Khalil, UNICEF Health specialist, South Eastern Region

Dr. Nadir Noori, PHD, Paktia

Mr. Habib Ullah, PEMT, Paktia

North/North-East Regions

Dr.Magdi Sharaf, WHO medical officer

Dr.Abdul Rahman Ghafoory, Regional Polio Officer

Basir Ahmad Afzali, REMT

Marwais Rabie, PHD, Balkh province

Dr. Wahid Bhurt, Medical Officer, Kunduz

Dr. Saboor Sozan, REMT Kunduz

Dr. Abdul Ahad Hakimi

Dr. Assadullah Naimi, APW Fiazabad

Dr. Aziz Ullah Safar, PHD, Kunduz




Western Region

Dr. Hakim Sadiq, Regional Polio Officer

Dr Gholam Said Rashed, PHD Heart

Dr Wahid Rahmani, REMT

Iskandar Hena, Medical Officer

Dr Rabbani Wardak, UNICEF Health and Nutrition specialist

Central Region

Dr Pirzad, National Expert Review Committee (ERC)

Dr Ahmoni, ERC.

Dr Shoban, Chair of ERC.

Dr. Ghulam Raziq Sidiqi, Regional Polio Officer

Dr. Fazel Karim, PHD, Kabul

Dr. Naseer Tahiri, PEMT Kabul

Michael and WHO driver, Habib




Annex 2: Schedule

August 6 (Thursday)

• Arrival 19.30 (Dr.Tahir, Mamdouh, Savita to meet mission at Kabul Airport)

• Security Briefing 20.30 at Hotel Heetal Plaza by Mr.Juma Din UNICEF

Security Officer

August 7 (Friday)

• Activity 1: Plenary Session at 9.00 AM-11.00 AM: Venue Main ConferenceHall WHO

o PE Operation and Service Delivery System Dr. Dost o Polio Situation update and Epidemiology Dr.Tahir Mir o National Update on Polio Communication Dr. Nafi / Savita o Country Update on routine EPI services Dr Dost

Participants: 5 participants each from Central, North and North East Region(PHD, REMT, WHO M.O, RPO,UNICEF Officer), Country Team Members(Dr.Tahir, Dr.Dost, Dr.Gula Khan, Dr.Nafi, Dr.Roohulla, Dr.Ali Ahmed,

Dr.Brando, Dr.Zara, Dr Bahrami,Savita), WR & UNICEF Representatives.

• Activity 2: Group Discussions by each Region 11.00 to 16.30 Venue is PolioMeeting Room

o Central Region Team (PHD Kabul, REMT, WHO M,O, RPO C.R,UNCEF C.R) 11.00-12-30

o North East Region Team (PHD Kunduz, REMT, WHO M.O, RPO N.E,UNICEF N.E) 13.30-15.00

o Northern Region Team (PHD Mazar, REMT, WHO M.O, RPO North,UNICEF North) 15.00-16.30

August 8 (Saturday)

• Activity 1: Meeting members of National Expert Review Committee (ERC)8.30-09.45 am

o Chairperson & members of National Expert Review Committee

• Activity 2: Meeting with Dr. Nadera Hayat Burhani, Deputy Minster of PublicHealth 10.00-11.00 am at office of Minister

• Activity 3: Meeting with Ibn-e-Sina (BPHS NGO) at 14.00 to 15.00 at Ibn-e-Sina (Arzan Qeemat)

• Activity 4: Meeting with Dr Sayed & Kees in World Bank 1530 - 1630

• Activity 5: Meeting with NATO / ISAF at ISAF HQ 1800 - 1900

August 9 (Sunday)

• Activity 1: Travel to Jalalabad by USAID flight 0900

• Activity 2: Field visit to Sub district B (Behsud): Briefing on Polio vaccinationCampaign and Communication initiative by the local teams 9.30 – 10.30

• Activity 3: Plenary Session: Venue MoPH 10.30 am – 11.30 amo Regional Polio update and Epidemiology - WHOo Update on Communication Initiative - UNICEF

• Activity 4: Group Discussions:o Session I: All PHDs and PEMTs: Venue MoPH 11.30 AM – 12.30 PM




Participants: All PHDs and PEMTs (Nangarhar, Kunar, Laghman & Nuristan), WHOM.O, RPO, UNICEF

• Activity 5: Meeting with Governor of Nangarhar followed by Lunch 12.30 PM–2.00 PM

• Activity 6: Meeting with BPHS NGO at HNI office (HNI, BRAC, ARCS and CWS

are responsible for the health service delivery in Nangarhar, AMI in Laghmanand Kunar and IMC in Nuristan) 2.00 – 3.30 PM

• Activity 7: Security briefing by the UNDSS ER UNICEF Office 3.30 – 4.00 PM

• Group Discussions: (continued)o Session II: UNICEF Group: Venue UNICEF 4.00 - PM – 5.00 PMo Session III: WHO Group: Venue WHO 5.00 – PM - 6.00 PM

• Dinner at WFP Guest House with Regional heads of UN agencies(UNDSS, UNICEF, UNAMA, OCHA, WFP, UNHCR and ICRC) 8.00 PM

August 10 (Monday)

• Activity 1: Departure Jalalabad 0730 & reaching Kabul by UNHAS flight at0930

• Activity 2: Plenary Session with Southern Region Team at 1030 to 1200Venue WHO Main conference room Kabul

o Regional Polio update and Epidemiology By WHO M.O o Update on Polio Communication in SR By UNICEF

Participants: All PHDs and PEMTS from South (Zabul, Kandahar, Helmand,Uruzgan, Nimroz, Farah), WHO South (M.Os, NHC, RPO, ARPO, 06 PPOs),UNICEF South (Head of the office, 03 PPCOs, RPPCO , FP Farah)

• Activity 3: Group Discussions 1300 to 1600 Venue Polio meeting roomWHO Office

o Group 1: All PHDs and PEMTs, 1300 - 1400

o Group 2: UNICEF Group 1400 - 1500 o Group 3: WHO Group 1500 - 1600

August 11 (Tuesday)

• Activity 01: Travel to Kandahar by CIDA flight around 0700

• Activity 02: Meeting at KAF (0900 -1130)o Meeting with TFK,o Meeting with ROCK,o Meeting CIDA

• Activity 3: Travel back to Kabul by CIDA flight

•

Activity 4: Meeting with AHDS (BPHS NGO) at 14.30 to 15.30 at AHDS(Shahre Nao)o Country office will be requested to invite Kandahar office In-charge in

this meeting. • Activity 5: Meeting with DFID (responsible person for Helmand) at 16.00 to

17.00 at DFID office. Status TBC

August 12 (Wednesday)

• Activity 1: Meeting with ICRC at 08.00-09.00 at ICRC Office




• Activity 2: Meeting with SRSG at 0930-1000 at SRSG Office

• Activity 3: Meeting with USAID at 11.00- 12.00 at USAID Office • Activity 4: Meeting with Animal Health Department, Ministry of Agriculture

(Mike) at 11.00 – 12.00

• Activity 5: Meeting with Ibn-e-Sina (BPHS NGO) at LUNCH at WHO

• Activity 6: Group Discussions by Region 13.30 to 16.30 Venue is Polio

Meeting Room o South-Eastern Region Team (PHD Gardez, REMT, WHO M,O, RPO

S.E, UNCEF S.E) 13.30 - 15-00 o Western Region Team (PHD Herat, REMT, WHO M.O, RPO West,

UNICEF West) 15.00 - 16.30

August 13 (Thursday)

• Activity 1: De-briefing Meeting with H.E Minister of Public Health & PolioPartners at 1330 - 1530 at MoPH

• Activity 2: Meeting with CIDA at 1600 -1630 at Canadian Embassy

August 14 (Friday)

Informal meeting & discussion with WHO and UNICEF Polio Team at 1000

August 15 (Saturday)

• Departure: Kabul to Dubai by UNHAS

Eastern Region UN security team with

Ben and Stephanie

Polio Evaluation AFG

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Transcript of Polio Evaluation AFG