Cross-border initiative on polio eradication in the Horn of Africa
Samuel Oumo Okiror,i Anthony Kisanga,ii Bal Ram Bhuiiii
Corresponding author: Samuel Oumo Okiror; e-mail: firstname.lastname@example.org
i WHO Regional Office for Africa, Brazzaville, Congo
ii CORE Group Polio Project, South Sudan
iii CORE Group Polio Project, Horn of Africa Regional Secretariat
© WHO Ethiopia/Erkkila Viivi
The Horn of Africa was hit by a wild poliovirus (WPV1) outbreak in April 2013 with a record number of cases: 194 in Somalia, 14 in Kenya and 9 in Ethiopia. While the outbreak occurred primarily in Somalia, it spread into bordering areas of Kenya and Ethiopia. At around the same time the Global Polio Eradication Initiative (GPEI) had entered a new phase with a significant reduction in case counts in endemic countries and a heightened recognition of the risk for the international spread of the virus. To combat the international spread, in May 2014, WHO declared polio a public health emergency of international concern and issued recommendations requiring proof of polio vaccination for travel to and from countries experiencing polio cases.
At the 7th Horn of Africa Technical Advisory Group (TAG) meeting held in February 2012, it was noted that the risk of significant WPV outbreaks was primarily due to, evidence of undetected circulation of WPV in countries, large pools of susceptible children, and geographically inaccessible areas due to security issues. In addition, because of the large number of pastoralists affected by or at risk for polio in the Horn of Africa, the TAG stressed the need for better cross-border initiatives as a compelling strategy for polio eradication in the Region.
In response to these recommendations, WHO and the CORE Group Polio Project (CGPP) launched cross-border initiatives in Horn of Africa countries. In August 2012, cross-border meetings were held at four sites in Ethiopia bordering with Somalia, Djibouti, Kenya, South Sudan and Sudan. Since then, over 28 cross-border counties/districts/regions have collaborated and initiated cross-border discussions and activities.
The objective of these cross-border meetings is to coordinate efforts to strengthen surveillance, routine immunization and supplementary immunization activities (SIAs) for polio eradication among bordering areas. Specifically, the initiative aims to improve information sharing between countries on polio eradication, identifying and addressing immunity gaps in migrant and hard to reach populations along borders, and planning for synchronized SIAs along borders.
The cross-border meetings involved communication between governments at national and local level and were held in border areas. WHO, UNICEF, CORE Group and NGOs supported the process, which involved sharing the situation analysis from both sides including mapping of border areas with a focus on communities, population movements, socioeconomic and cultural status, health behaviours and health resources.
Participants of cross-border (South Sudan and Uganda) meeting held in Kajo Keji, July 2014
The meetings verified that there is significant movement of population between countries for trade, employment, pastures, health care and cultural reasons. In addition, refugees and those affected by clan conflicts also frequently move across borders. These border areas vary in terms of socioeconomic status, heath infrastructure, and health seeking behaviour of the population and there has been a lack of information sharing between health management across borders. Polio eradication activities, coordination and synchronization of SIAs and acute flaccid paralysis (AFP) surveillance have also been lacking. In general, the border communities are hard to reach, underserved and at high risk for polio.
This cross-border initiative has brought together border stakeholders to discuss and plan ways to jointly combat the circulation of polio. Joint action plans, which focused on activities to be carried out in individual countries, activities needing synchronization, sharing of information, and joint review and planning, have been developed. Cross-border coordination committees have been formed and focal persons on both sides of the border have been designated. At some crossing points, static polio vaccinations team have been established and have vaccinated thousands of children. The action plans also call for resource mobilization to ensure implementation.
The implementation of these cross-border initiatives is going well despite some critical challenges. A major challenge is the lack of resources from collaborating governments. As a result, government ownership and leadership is minimal. The cross-border initiative is designed based on a coordination model where parties enjoy autonomy and independence, use their own resources to carry out committed activities, and come together regularly to review and improve further partnership. The governance structure for the cross-border initiative is informal and weak, in part due to a lack of a comprehensive framework and guidelines to inform its planning, implementation and monitoring and evaluation.
WHO-AFRO has developed draft guidelines, which provide a clear framework for improving the success of cross-border initiatives. WHO and the CORE Group will review its current cross-border initiatives using these guidelines and will advocate for and provide support to countries for improved effectiveness.
CORE Group Polio Project. Reports on cross-border meetings in South Sudan and border countries, 2012–2014.
Federal Ministry of Health of Ethiopia. Meeting report on cross-border collaboration for polio eradication in the Horn of Africa. 2012.
WHO. Enhancing Implementation of Cross-Border Initiative on Epidemic Diseases and Other Public Health Issues in the WHO African Region. Regional Office for Africa.
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