This sixth installment in our series on U.S. support for global polio eradication explores the evolution of the Global Polio Eradication Initiative, discussing how its multi-layered governance model, while unwieldy at times, has proven the value of partnerships through its success.
The Global Polio Eradication Initiative (GPEI) is one of the largest public health programs ever.
Over the last 30 years, the program has engaged millions of health workers and volunteers, delivered polio vaccines to the most remote corners of the planet, and managed billions of dollars. The organizational and logistical challenges have been enormous as the five core partners worked with national governments and other collaborators to extinguish the polio virus in every part of the world.
“GPEI as it is now… really is a unique governance structure which no other health program has been able to follow... I’m sure that to the extent that eradication has been successful, it’s due not least to this governance structure.”
– Bjorn Melgaard, Independent Global Health Policy Consultant
A child in Vanuatu is vaccinated against polio
| UNICEF via Getty Images
The World Health Organization (WHO), UNICEF, Rotary International, the U.S. Centers for Disease Control and Prevention (CDC), and the Bill & Melinda Gates Foundation lead the initiative through a unique governance structure that evolved organically based on the needs of the program and the desires of partners and major donors. The resulting multi-layered, somewhat bureaucratic alliance has been highly effective despite its flaws, reducing the number of wild polio cases worldwide by more than 99 percent.
The GPEI has proven the power of partnerships—including with the private sector—and shown the value of a consensus-based, inclusive management approach that has strengthened and solidified partner commitment over time. While a full replication of the GPEI is unlikely given its scale and single-disease focus, these structural features hold important lessons for other global health initiatives.
In 1988, a World Health Assembly resolution committed all countries to global polio eradication. The initiative was launched as a small program within the WHO’s immunization division, the Expanded Programme on Immunization (EPI). It was led officially by WHO but supported through an informal alliance with the original partners, UNICEF, CDC, and Rotary. The number of polio cases fell rapidly at first, as countries with solid immunization systems added the vaccine to their schedules or used their existing networks to conduct national polio immunization campaigns.
World Health Organization meeting in 1988 that resulted in the founding of the GPEI
| WHO
“One of the things that makes [the GPEI] unique is that it wasn’t organized initially around a governance structure and it continues to be unconventional. At the start, it was a freeform alliance of different organizations each raising money."
– Ellyn Ogden, Worldwide Polio Eradication Coordinator, U.S. Agency for International Development
The initiative encountered its first obstacles when it began to focus on regions with weaker health infrastructure that had fewer health workers and financial resources. Since these countries lacked strong existing immunization networks, the task of reaching every child required the program to organize and fund vaccination campaigns itself, including resource-intensive house-to-house vaccine delivery.
In Bangladesh, a doctor and her assistant prepare to take polio vaccines via rickshaw to families in local slums
| Gavi
As the eradication program’s responsibilities grew, so did its need for financing. When the program began, planners predicted the task of polio eradication would cost $155 million and be completed by 2000.¹ Instead, its budget has hovered around $1 billion a year since 2011, and total costs are now $17 billion over its lifetime.²
By 1998, the program was still struggling to meet its goals. WHO increased its advocacy and fundraising efforts and hired a director devoted specifically to polio eradication. With new management and focus, the program picked up steam. In order to gain visibility and develop its own fundraising brand, the GPEI began to operate separately from the EPI under the name of the Global Polio Eradication Initiative.
In the mid- to late-2000s, the initiative stalled again. The GPEI had been missing targets and struggling to extinguish the virus in the last few endemic countries: India, Afghanistan, Pakistan, and Nigeria.³ GPEI management was criticized for its lack of transparency and being unduly positive about the program’s progress. Some criticized the initiative for its overly centralized, inflexible operational style that allowed it to “stick doggedly to a particular course of action, regardless of whether it was working or not.”⁴
These issues, combined with a failure to achieve eradication, led to dissatisfaction among some partners, which now included the Gates Foundation. The partners commissioned several management reviews starting in 2010 and developed new oversight bodies. These included the Polio Oversight Board (POB), a panel of the top executives from each of the core partners, and the Polio Partners’ Group, which pulled together a range of donors and other stakeholders. An accountability mechanism also was added—the Independent Monitoring Board of the Global Polio Eradication Initiative (IMB).
The IMB began issuing assessments that often were critical of GPEI management. For example, in a 2011 report it asked, “How can it be that individuals known to be tired and ineffective are allowed to remain in key leadership positions?”⁵ WHO ultimately reconfigured its polio team, the other four core partners took on stronger decision-making roles, and governance became more horizontal and consensus-based.
“If you look back at the structures we had to accommodate, all the different partners and agencies that wanted to have a stronger voice, it made [the GPEI] evolve into a fairly unwieldy bureaucracy because of the expectation that each agency would be represented on every level of technical as well as decision-making bodies.”
– Brent Burkholder, Independent Global Public Health Consultant
The structure now operates without a central authority, and all the partners spend an enormous amount of time discussing issues and deciding on a course of action as a group. Despite the loss in efficiency, the GPEI has continued to improve eradication infrastructure while ensuring continued partner commitment.
In the late-2010s, the program began facing fatigue on the part of some country-level administrators and resistance from some parents of children repeatedly approached by polio vaccinators.⁶However, a more pressing concern has been the national and geopolitical obstacles in the remaining endemic countries that limit its access to unvaccinated children.
In April, the Afghanistan Taliban banned WHO from operating in its territory.⁷ The Pakistan program has suffered deadly violence against polio vaccinators fed by unfounded rumors about the vaccine and by the program’s (false) association with the U.S. hunt for Osama bin Laden.⁸ Insecurity and insurgent activity by Boko Haram in northern Nigeria has blocked both vaccination campaigns and disease surveillance efforts.
Pakistani children look at a health centre torched by a mob following rumors of reactions to polio vaccination in April 2019
| Abdul Majeed/AFP/Getty Images
“At this point, a fundamental issue preventing eradication is lack of access to unvaccinated children. It’s not that we merely need a better manager or improved supply chain to achieve eradication—the fundamental issue is lack of access in areas controlled by anti-government elements.”
– Amb. John Lange, Senior Fellow, Global Health Diplomacy, United Nations Foundation
As the GPEI attempts to respond to new challenges, management entities—largely task teams and working groups—have proliferated. In a somewhat ironic result, the GPEI governance structure has grown dramatically, even as its global caseload has shrunk. This reflects the complexity of the polio endgame. The GPEI still labors to reach its ultimate goal, and it is unclear whether the strategic management expansion has truly helped.
“The reasons that polio has not been eradicated really aren’t related to the organization structure in Geneva. So no amount of restructuring in Geneva will get us to eradication. And they know that.”
– Mara Pillinger, PhD Candidate, The George Washington University
In October 2018 an independent team commissioned by the IMB to review progress in the remaining endemic countries questioned whether “this elaborate structure remains fit for purpose, or whether it may now be a drag on country level efforts.”⁹ Others note that much of what is hindering eradication at this point is beyond the control of program management. “The fight to eradicate polio will be won (or lost) on the ground," one researcher noted. "Even if GPEI HQ were to implement the most successful change initiative of all time, the program’s key security, political, and socio-cultural challenges can only be solved at the country level.”¹⁰
By working at both the country and global levels, private-sector organizations have driven and sustained what is essentially a public health campaign. Rotary, an international service organization with 1.2 million business and professional members, committed to polio eradication as an organizational goal in the mid-1980s.
A member of Rotary Club give biscuits to a child after he receives polio vaccine drops
| NARINDER NANU/AFP/Getty Images
So far, Rotary has donated $1.9 billion to the effort. In addition, Rotary members have volunteered for local vaccination campaigns and advocated for the initiative at all levels of government. Despite being a private-sector organization, Rotary has been a key partner in GPEI management from the very beginning.
The Gates Foundation first joined the GPEI in the early 2000s as a donor but has since become one of its most active partners. Polio eradication is now one of the Gates Foundation’s top priorities, and Bill Gates personally urges government officials and donors to maintain their commitments.
Bill Gates with Nigerian President Mohammadu Buhari (R) in 2016 after reaching a commitment on Polio Eradication
| Philip Ojisua/AFP/Getty Images
In addition to providing technical, policy, and programmatic support, the foundation is now the GPEI’s top donor, with contributions totaling $3.6 billion as of the end of 2018. By comparison, the U.S. government has contributed $3.3 billion over the past 30 years.¹³
The Gates Foundation notes that it plays a unique role in the GPEI because it has the “ability to contribute by taking big risks and making nontraditional investments. Examples include our investments in vaccine research and our establishment of emergency operations centers in Nigeria, Pakistan, and Afghanistan.”¹⁴ With its enormous resources and flexibility as a private-sector entity, the Gates Foundation has been able to identify and respond immediately to program gaps that the frequently cash-strapped WHO, CDC, and UNICEF would have been hard-pressed to address.
While Rotary and the Gates Foundation play a pivotal role in the GPEI, some speculate that the program’s high visibility and association with U.S. organizations may now be hurting the effort. The program has been struggling to extinguish the virus in areas of Pakistan and Afghanistan that have a high concentration of anti-Western sentiment. While U.S. support will remain critical to successful eradication, the current environment seems to call for yet another governance and communications shift in order to lower the GPEI’s profile in these challenging geographies.
This realignment will also require integrating polio vaccination more into country immunization programs rather than operating through separate vaccination campaigns. In exploring that option, the POB has added the executive director of Gavi, the Vaccine Alliance, to its membership. Gavi focuses on the provision of a range of vaccines to low-income countries.
“The governance structure of a mostly vertical program such as polio eradication has all of these difficulties as it comes very close to reaching its goal, but the only way it can really succeed and sustain the gains is through a horizontal routine immunization program that will maintain essential polio functions.”
– Amb. John Lange, Senior Fellow, Global Health Diplomacy, United Nations Foundation
This new partnership has required some adjustment but to many is long overdue. The IMB recommended as early as October 2014 that the GPEI make Gavi part of the partnership as a way to boost its commitment to broader immunization systems. “Although it appears prominently in the strategic plan, routine immunisation is treated by the main body of the polio programme as if it is some side issue – a ‘nice-to-do’ not a ‘need-to-do’,” the IMB noted. “This is short-sighted. It may, in Pakistan, be key to reaching those children whose parents are fed-up of repeated polio-only campaigns but would willingly accept a package of vaccinations for their children.”¹⁵
Despite eradication’s many challenges and the GPEI’s potentially cumbersome structure, the GPEI continues to operate effectively. Its unique use of a consensus-based “club governance model” allows partner principals to operate as a unit separate from their parent organizations.
“The GPEI is an impressive management entity, with a cohesive amalgam of partners that has embraced a common goal and ceded policy-making powers to this body in pursuit of that goal,” noted the Transition Independent Monitoring Board, a panel convened to oversee the integration of polio infrastructure into country health systems. Through this alliance, the initiative “has created a leadership and accountability function that is unprecedented in global health,” the board added.¹¹
The longstanding engagement of all partners and their leaderships’ direct buy-in through the POB has given the polio program unmatched commitment both to the goal of eradication and to the partnership itself. “The core partners consider themselves as being in a long term, close-knit relationship. They are in this together until the end; they will succeed or fail as a unit; and they are committed to collaborating to get the job done.”¹²
Indian schoolgirls hold signs celebrating their country being polio-free in 2012
| NOAH SEELAM/AFP/Getty Images
There is a commitment in the organization that goes beyond anything else that I’ve seen in any other public global health program."
– Bjorn Melgaard, Independent Global Health Policy Consultant
Over time, the GPEI has proven the value of strong partnerships where each organization has an equal say and illustrates the vital role the private sector can play in public health. It also reflects how governance changes, painful as they may be, are part of a necessary evolution to respond to realities on the ground.
The last chapter for polio eradication remains to be written, and other reforms may be necessary before the program can succeed. However, the GPEI’s commitment to inclusive management will continue to offer important lessons for the successful implementation of other global health programs.
Nellie Bristol is a senior fellow with the CSIS Global Health Policy Center. She leads the Center’s work on efforts to repurpose polio eradication assets for long-term disease control and toward other global health priorities. In addition to an active working group convened to discuss eradication and transition as it relates to U.S. global health policy, she writes extensively on the issue and consults with other organizations focused on transition planning. She also writes about U.S. government relations with multilateral organizations, including the World Health Organization and the World Bank Group. Her major reports for CSIS include Catalyzing Health Gains through Global Polio Eradication, which focused on polio transition in India; Bolstering Public Health Capacities through Global Polio Eradication, which examined polio assets in Ethiopia; The Power of Straight Talk, which looked at the impact of the Independent Monitoring Board on eradication efforts. Bristol came to CSIS following a long career as a health policy journalist. She spent two decades writing about domestic health policy on Capitol Hill before expanding her coverage to global health in 2005. Bristol has written for top publications in the field including The Lancet, Health Affairs, and Congressional Quarterly, covering HIV/AIDS policy, foreign aid and national security, noncommunicable diseases, and efforts to combat maternal mortality. She holds a master’s degree in public health/global health from George Washington University.
Michaela Simoneau is a program coordinator and research assistant for the CSIS Global Health Policy Center, where she supports the polio, immunization, and nutrition portfolios. Prior to joining CSIS, she worked as an intern on projects concerning antimicrobial stewardship, conflict resolution, and human rights, and managed her university partnership with a grassroots non-profit organization in Coimbatore, India. Ms. Simoneau holds a B.S. in Biology and International Studies from Boston College, where she wrote her senior thesis on the Rohingya refugee crisis.
This project is made possible through the generous support of the Bill & Melinda Gates Foundation.
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