GPEI’s Funding Decline Among Tedros’ Top Challenges as WHO Director-General

Among the pressing issues facing incoming World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus when he begins his term July 1 is the winding down of the Global Polio Eradication Initiative (GPEI). The polio program comprises 27 percent of total WHO expenditures and provides support for disease surveillance, immunization delivery, and laboratory capacity along with data collection and analysis not only for polio, but other diseases as well. WHO still is analyzing what the reductions will mean specifically for the organization’s activities, but it notes, “the current downscaling of the polio infrastructure, together with that planned for the future, will cause WHO to lose its field presence, coordinating role, and technical leadership in some countries in greatest need.”

Among those is Tedros’ home country, Ethiopia, which receives the fifth highest amount of external polio-related funding of any country at $40 million in 2016. That amount currently is slated to decline to $4.6 million by 2019, an 88.5 percent decrease. Polio-funded NGOs provide immunization and other health services to Ethiopia’s hard to reach border areas where government services are scarce.

The World Health Assembly, the May annual meeting of country health ministers which sets policy for WHO, this year noted “with great concern” the organization’s reliance on polio-related funding at the global, regional, and local levels. It cited “financial, organization, and programmatic risks” the dependence creates “including risks for the sustainability of WHO’s capacity to ensure effective delivery in key programmatic areas and to maintain essential continuing functions.”

The body urged the WHO Director-General to develop a strategic action plan by the end of the year to respond to the funding decrease and to explore alternative methods of maintaining budget levels. WHO Executive Director Ian Smith told health ministers that WHO already has prepared briefings for the new D-G and is addressing the issue in other ways including through the organization’s financing dialogue to be held later this year.

To respond to the transition challenge, WHO is working with GPEI partners and donors, both those contributing to polio and to a broader pool, as well as organizations like Gavi, the vaccine alliance, that also benefit from the polio infrastructure. To make the best case for polio asset continuation, WHO will need to provide detailed data about the value of polio staff to broader health activities. While countries should lead their own planning efforts, it will fall to WHO to ensure polio infrastructure is used to support regional and global disease surveillance networks and employed optimally to aid global emergency response capabilities. WHO also should take on securing continuation of polio “essential functions”--immunization, surveillance and virus containment-- an activity that may require establishment of a smaller international body that dovetails with the GPEI as the initiative tapers off.

GPEI reductions will hit WHO’s African region (AFRO) the hardest. Polio funding currently makes up 44 percent of WHO expenditures in the region. The Eastern Mediterranean region (EMRO) is not far behind at 43 percent. Sixteen countries (Afghanistan, Angola, Bangladesh, Cameroon, Chad, Democratic Republic of the Congo, Ethiopia, Indonesia, India, Myanmar, Nepal, Niger, Pakistan, Somalia, South Sudan, and Sudan) receive more than 95 percent of the GPEI’s resources and are priorities for transition planning.

It is not surprising that AFRO and EMRO receive the bulk of polio funds, given that the remaining endemic countries, Nigeria, Afghanistan, and Pakistan, are in those regions and are the top recipients of GPEI resources. In 2016, Nigeria required $247 million in external funding for polio-related activities, while Pakistan required $210 million, and Afghanistan $79 million. Some of the funding goes toward polio vaccination campaigns which could safely be scaled back once polio-free status is established. Further, some staff needed to eradicate polio, including the massive cadre of vaccinators required to administer polio drops in all regions, will not be necessary, or necessarily qualified, for other activities.

But other personnel are essential, both for continuing polio functions post eradication and for other public health activities. WHO estimates that 23 percent of its polio-funded staff contribute to broader immunization and surveillance activities, 19 percent provide technical support to the Expanded Program on Immunization, and 56 percent facilitate operations for surveillance and immunization activities through WHO country offices. In addition, polio program-funded emergency operations centers, surveillance systems, and laboratories contribute to WHO’s global disease control capabilities and could engender progress toward health security, measles and rubella elimination, and immunization expansions among other goals.

While WHO headquarters is gearing up its transition activities, regional offices and national governments have been working on their plans for months. AFRO has developed at least a preliminary strategy to address the funding reduction and is writing a business case for immunization that will lay out what is needed for African countries to meet Global Vaccine Action Plan targets as the GPEI winds down. Further, the GPEI has developed transition planning guidelines for countries and is monitoring progress toward completion. The Polio Oversight Board, comprised of the heads of the five core polio partners, also appointed a Transition Independent Monitoring Board to guide the process.

Despite the activity, many say planning has proceeded too slowly. Africa’s Regional Immunization Technical Advisory Group commented in December: “polio transition is inevitable and is imminent, urgent attention to better planning is required to avoid adverse impact on immunization, surveillance and emergency response programs.” Indeed, overall GPEI funding levels already dropped this year from $1.4 billion in 2016 to $1.1 billion in 2017 and AFRO has begun reducing staff in some countries, although officials say at this point mostly through attrition or affecting largely only support personnel.

In addition to programmatic gaps, WHO also confronts a self-acknowledged “reputational risk” if it doesn’t handle polio transition well. The historic success of polio eradication would be tainted if low-income country immunization systems subsequently begin to falter. Although the GPEI is an international partnership comprised of the U.S. Centers for Disease Control, Rotary International, UNICEF, and the Bill & Melinda Gates Foundation along with WHO, it is WHO that likely will bear the brunt of any criticism if polio transition fails. It will fall to Tedros and his staff to develop a solid, evidence-backed transition plan that ensures the significant the investment in polio eradication continues to engender public health progress long after the GPEI has dissipated.

Nellie Bristol
Senior Associate (Non-resident), Global Health Policy Center