Mobilizing Political Support Proved Critical to a Successful Switch from tOPV to bOPV in Kano, Nigeria 2016

"Our findings re-affirmed that enlisting political support and building partnerships are key areas that need to be addressed for successful implementation of public health interventions..."

With an eye to reducing the risk of circulating vaccine-derived poliovirus (cVDPV), the World Health Assembly in 2013 endorsed a plan that calls for the ultimate withdrawal of oral polio vaccine (OPV) from all immunisation programmes globally. The withdrawal was to be conducted in a phased manner with the removal of the type 2 component of OPV in 2016 through a global switch from trivalent OPV (tOPV) to bivalent OPV (bOPV). This study assessed the impact of political leadership engagement in mobilising other stakeholders on the outcomes of the tOPV-bOPV switch in one of the key high-risk states for polio transmission in Northern Nigeria. Specifically, the paper describes the process of political leadership engagement of various stakeholders, the role played by individual stakeholders, and the impact of this collaboration in the successful implementation of the switch between February and April 2016 in Kano state.

One reason the researchers chose to focus their investigation on Kano is the interplay between politics and immunisation in this state. Misunderstandings and inadequate communication led Kano state to a boycott polio immunisation in 2003–2004 with devastating consequences to the Global Polio Eradication Initiative (GPEI). Immunisation sceptics propagated the rumour that OPV was unsafe. Therefore, any misinformation on the withdrawal of tOPV to prevent VDPV could play into the hands of these sceptics. Kano state health authorities felt there was a need for transparency, but the information should be passed in such a way that it contains no unnecessary details to spark controversy. In addition, there was a wide range of stakeholders handling tOPV in the state. Major stakeholders were private medical practitioners, pharmaceutical companies, and security agencies. Political leadership was required to effectively engage them for assured and complete withdrawal of tOPV.

The paper details the advocacy work conducted. The state switch committee established the state switch support team, which comprised representatives of state primary health care development board (SPHCMB) and all partner agencies. The support team developed a detailed switch plan for the state and supported its implementation. Similar support teams were established in all the 44 local government areas (LGAs). The state switch committee paid an advocacy visit to the state Health Commissioner and briefed him on the switch plans and requested his active participation in the switch process. He was specifically asked to lead in the media engagement and other stakeholder engagement. The Health Commissioner convened series of meetings with representatives of private health practitioners, where he highlighted the importance of the switch process and specific actions required from them. The Health Commissioner also issued a directive to all public health facilities in the state to ensure availability of routine immunisation (RI) focal persons even outside working hours in the week of the switch. Additionally, letters on the switch were written to commandants of all military and paramilitary health institutions in the state, and weekly review meetings were held on the challenges and the solution to the switch process under the Health Commissioner.

The researchers find that the Kano state Ministry of Health provided clear leadership in the switch process. The Health Commissioner led the media engagement, which was considered critical due to the sensitivity and the misunderstanding that often surround Polio Eradication Initiative (PEI) interventions in the state. Part of media engagement activities conducted by the commissioner included a media briefing on the switch day, which attracted public and private media representatives. The Commissioner highlighted objectives of the switch, and the participants were given an opportunity to ask questions and seek clarifications on any issue about the switch.

A total of 670 health facilities that provide RI services were assessed during the pre-switch activities. Health workers were aware of the switch exercise in 520 (95.1%) of the public health facilities assessed. It was found that health workers knew what to do should tOPV be found in any of the 521 (95.2%) public health facilities assessed. However, there was a wide disparity between the public and private health practitioners' knowledge on basic concepts of the switch. For example, only 60.2% of workers in private facilities knew which polio vaccine to be used after the switch (versus 96.3% in public facilities).

There was 100% withdrawal of tOPV from the state and the 7 zonal cold stores. Unmarked tOPV was found in the cold chain system in 2 (4.5%) LGAs. Only one health facility (0.8%) had tOPV in the cold chain. No tOPV was identified outside the cold chain without the "Do not use" sticker in any of the health facilities.

The researchers conclude that the engagement of political leadership to mobilise other key stakeholders facilitated successful implementation of the switch exercise in Kano. They recommend sustained advocacy to the political leadership for increased guidance in enlisting the support of critical stakeholders - private and public - in planning, implementating, monitoring, and supervising public health interventions.