Five lessons from Nigeria's polio eradication efforts

On July 24^th Nigeria celebrated a huge milestone in the global effort to eradicate polio. It has been one year since the country has had a case of wild polio. This means that it has interrupted transmission of the crippling disease.

 
Before the advent of polio eradication efforts, Nigeria suffered from many thousands of paralytic polio cases every year. Many of the crippled victims of the disease can still be seen, a stark testimony to the human costs of this preventable disease.
 
Now that Nigeria has interrupted transmission, it is two years away from being certified as having eradicated the disease. This will be a global public good of the first order! Now only two other countries-Afghanistan and Pakistan-have widely circulating wild polio virus and the world is on the cusp of polio eradication.
 
Besides the obvious benefit of preventing polio, the polio eradication effort in Nigeria has provided other benefits. The lessons learned from polio and the infrastructure developed were instrumental in successfully containing the Ebola epidemic that broke out in 2014. Polio has also provided the backbone for strengthening disease surveillance and public health throughout Nigeria.   

What are the lessons from Nigeria’s accomplishment? 

1. Combined efforts: This momentous accomplishment has been achieved, over more than a decade, through a combination of country leadership, local implementation and coordinated support from the World Bank and other development partners such as WHO, UNICEF, and the Bill and Melinda Gates Foundation. 
   The World Bank has provided continuous support towards polio eradication from 2003 to 2014 through two polio projects and additional financings worth $285 million. The Bank also just approved an additional financing of $200 million in April 2015 for polio operations and routine immunization.
   There has been an extensive and intensive collaboration between development partners. For example, much of the World Bank’s support to polio in Nigeria was supported by grant donors through a “buy down” mechanism which turned IDA financing into a grant if certain results (high polio immunization coverage) were achieved. The buy down represented a “win-win-win” approach for all stakeholders: the Government received grant financing for a global public good as long as it performed well; the Bank could leverage the technical expertise of other partners, and the grant donors were able to highly leverage their funding.
    
2. Persistence: Interrupting transmission was always going to be a challenge and so it was important to take a long-term view of the effort. Even two years ago it looked unlikely that Nigeria would be able to interrupt polio. In 2013 there were 53 reported cases of polio up from 21 cases in 2010 and Boko Haram had killed 9 polio vaccinators in targeted assassinations. It was only through stubborn persistence and optimism that Nigeria was able to turn the tide.
    
3. Use of Data: Walk in to the emergency operations center (EOC) established by the Federal Ministry of Health (FMOH) and every square centimeter of wall space is covered with graphs and tables. Behind the graphs and tables is a data collection system that is robust and uses multiple sources of information. Disease surveillance, coverage surveys, routine reports, and environmental sampling results are carefully scrutinized on an ongoing basis.
    
4. Innovation: Based on the data analysis strategies were re-evaluated and innovations tested to address major challenges. For example, polio vaccination coverage rates in the security-affected states in the North East of Nigeria were too low and so the National Primary Healthcare Development Agency and state governments developed a series of tactics to improve it. One of the approaches was called “hit and run” in which local vaccinators would move into a rural area in the morning, vaccinate children as quickly as possible and be gone by the afternoon.
    
5. Motivation: Having good data allowed managers to see how government and development partner staff were performing. Poorly-performing staff were either re-assigned or, in some cases, fired and the good work of high performing staff was recognized.   

Nigeria has made great strides and the interruption of transmission should be celebrated. However, there are still years of work to do before the final goal of eradication is achieved. There is also the challenge on building on the success of the polio effort to strengthen health service delivery more broadly. This, like the World Bank’s support to polio, will take a long-term commitment.

Follow the World Bank health team on Twitter:  @WBG_Health