The Fight Against Polio: A Project Management Approach
Micro planning, an iterative approach to project implementation, clearly defined roles and responsibilities, project ownership, and a comprehensive surveillance and monitoring system are some of the project strategies that help eradicate polio in India

On 13 January 2014, when World Health Organization (WHO) declared India free from the wild polio virus, a nation-wide campaign that was launched two and a half decades ago had come to an end. The global fight against polio started in 1988 with an initial timeline to eradicate the virus by 2000. However, real progress in India started only in 1995 when international agencies partnered with the Government of India and local administrative bodies, and involved thousands of healthcare and social workers, and local citizen groups to launch a mass campaign.

It was a campaign that ran like a project with a project management office (PMO) for its overall management, monitoring, and advisory role; clear roles and responsibilities of each project partner involved in the campaign; seamless partnership between the various agencies; field work backed up by continuous research to find a more efficacious vaccine; micro planning to cover different scenarios that front-line workers could face; an agile project management approach that empowered the field team to make quick iterations based on feedback from the ground to the overall plan to accommodate challenges faced locally; a multi-layered communication strategy that addressed both the overall objectives and concerns among citizens in a locality or community; and a rigorous follow-up and monitoring system that used both scientific data and human intervention to ensure the virus was not active in even the remotest corners of the country.

With over 170 million children under the age of five in India, every nationwide campaign had to cover each child multiple times a year. An army of 2.3 million vaccinators traversed the country to reach these children in over 200 million households.

Each year more than 39,000 health facilities in India, both in the public and private sector, were engaged in reporting cases with suspected paralysis due to polio. More than 60,000 such cases were investigated and more than 120,000 stool samples tested in eight WHO accredited laboratories annually. The monitoring system comprised of more than 3,000 monitors that identified gaps in the preparedness and implementation of polio vaccination campaigns, and provided reliable and timely data for programmatic action.

The biggest cost was towards the campaigns, budget for which came from the Government of India. It covered the costs for 2-3 billion vaccinations, logistics of running the campaigns, and creating awareness about them. There were two nationwide annual campaigns, plus additional campaigns in areas that the surveillance program identified as high-risk, such as in Uttar Pradesh and Bihar. The budget was around US$ 250-300 million.

Additional funding came from WHO and United Nations Children’s Fund (UNICEF) that trained 5,000 community mobilizers. Additional money was raised from the Global Polio Eradication Initiative. Over the past two years, the costs had come down. WHO also took care of the quality of data generated as well as evidence gathering and research for more efficacious vaccines.

Though the project objective was eradication of polio from India, there were a number of milestones and sub milestones. For example, there were milestones for coverage: the percentage of children to be reached in Bihar or UP within a set timeframe. There were also milestones in terms of surveillance of high risk areas.

Project Challenges
Keeping pace in vaccination was a challenge with growing population density in many states and 26 million births every year. The polio virus thrives in contaminated water and food. Poor sanitation and high diarrheal rates in parts of western UP and central Bihar made it extremely difficult to wipe out the virus.

There were social issues as some communities believed that vaccination could harm their children. There were also geographical barriers.

The campaign required huge funds and the Government of India remained resilient in its approach. If research did not throw up any concrete solution, the government was ready to try another route.

Technical challenges arose when the vaccines did not work in places with poor sanitation and high population density. WHO stepped up research work to come up with a better vaccine. There was also a challenge of setting up a surveillance system that had geographical representation, involved all categories of healthcare providers, and ensured timely reporting, investigation, and stool specimens collection of all children with sudden onset of paralysis. It needed the backing of an efficient and reliable laboratory network.

Project Management Strategies
“A decentralized process for planning and implementation of plans, with flexibility for real-time decision-making, and an inbuilt accountability framework was the hallmark of the initiative in India. All plans were developed at the block level with inputs from vaccinators and supervisors. There was emphasis on the involvement of local community influencers. The willingness to allow critical self-evaluation to identify lacunae, followed by a refinement and re-refinement of the strategies, was a critical element,” explains Dr. Menabde.

Project planning
PMO for the polio eradication campaign was in the immunization division of the Ministry of Health and Family Welfare, Government of India. A core committee comprising government officials, WHO, UNICEF, and Rotary International held weekly meetings to review progress regularly, make changes, and consider feedback. Above that, there was an operations group chaired by the health and family welfare secretary. Partners met once in two months or once a month, depending on the urgency.

There was also an India Expert Advisory Group for polio eradication comprising national and international public health experts, and social scientists that met twice a year to review the situation. The assessments and recommendations of the experts’ group helped define the initiative’s strategic roadmap.

The eradication effort involved meticulous planning. At the block level, all the vaccinators and supervisors chalked out micro plans. Each team of two would make a route plan that indicated the starting house and the last house to be covered in a day. In urban areas, vaccinators covered more houses than in rural areas where houses are far flung. The vaccination drive took place usually on a Sunday. And for the next two-three days, teams spread for house-to-house visits to vaccinate children who were not brought for vaccination.

Project Implementation
The hallmark of this initiative was the flexibility in its implementation strategies. All decisions regarding project implementation were taken at the district level by a district task force (DTF) headed by the district magistrate. For example, in western UP, farmers would leave for the farm at 7 am. Vaccinators here worked in early morning and late evening shifts instead of the usual 9 am to 4 pm time slot. In Mumbai, they went around the streets at night to look for homeless children.

In UP, field teams faced resistance in Muslim neighborhoods. To gain their confidence, local Muslim influencers were used and announcements made from mosques regarding upcoming campaigns.

Training was an important component for the project’s success as a substantial proportion of the 2.3 million frontline workers and volunteers were teachers, government officials, or social workers who had no healthcare background. All the vaccinators went through training conducted by WHO just before the campaign and budget for training was earmarked by the government.

Different communication strategies were used for the initiative. Film star Amitabh Bachchan was brought in to create awareness about polio vaccination for the nationwide campaign. Targeted communication strategies were designed to remove myths regarding polio vaccination. At the micro level, vaccinators who spoke local language were the real ambassadors of the program, convincing people and removing their fears about vaccination.

Monitoring of implementation of the campaigns was done at the district level, where a total of 3,000 people were involved. In case a child missed vaccination, information immediately reached the team and the child was vaccinated the next day at home. At the block level, a review meeting would take place on the day of the campaign were the gaps were identified and action proposed for correction the next day. A similar meeting would also take place the same evening with the district magistrate and the chief medical officer of the district. To close any gaps, wireless messages, instructions, and guidelines would go out to the field team.

An accountability framework was developed for everyone involved in the campaign. It used a robust mechanism that ensured feedback reached in real time and corrective action taken immediately.

The surveillance system surpassed global standards for performance indicators for accuracy in reporting, detection of paralysis and so on. This data showed which communities were affected, whether it was concentrated in one region, or the kind of polio virus. It helped to decide the type and frequency of the vaccine.

Consistent analysis of data showed where more monitoring was needed. Analysis showed that the polio virus had found a sanctuary around the Kosi river in Bihar. The nature of the terrain and flooding had made it difficult for vaccinators to reach that area. An operational plan was put in place. A field team set up a camp in that area and started monitoring and implementing the program. The team came up with micro plans to cover each child through additional vaccination drives.

A campaign of this magnitude reached its goal of eradicating the polio virus that had paralyzed thousands in this country by following a detailed project plan, seamless coordination between agencies, a system that promoted empowerment and accountability for each one involved in the project, execution with constant monitoring and follow-ups, and of course, the grit and determination of the thousands of volunteers and workers.

“The program in India saw many ups and downs but it never gave up. The perseverance it demonstrated was unmatched and ensured that it stayed on the right path,” says Dr. Menabde.