Improving Immunization and Fighting Polio in Pakistan

Polio remains endemic in only two countries: Afghanistan and Pakistan. Apart from polio campaigns, broader support for immunization is essential to eradicate polio. Two weeks ago (on April 21, 2016), the World Bank approved an International Development Association (IDA) credit of $50 million to increase the availability of vaccines for infectious diseases, including polio, for children under two years of age in Pakistan.  Additional funding to the amount of $80 million is provided by a World Bank administered multi-donor trust fund, Gavi – the Vaccine Alliance, and the United States Agency for International Development. The Bill and Melinda Gates Foundation also participates through a buy-down mechanism (on what a buy-down amounts to, click here). Below is information on the project reproduced from the World Bank’s website (the original link for the information is here).

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The National Immunization Support Project (NISP) is supporting the country’s Expanded Program on Immunization (EPI) that aims to immunize all children against eight vaccine preventable diseases:  tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type b (Hib), and measles. Strengthening EPI will also support Pakistan’s access to newer vaccines which are either in the process of roll out (pneumococcal vaccine) or under planning (rotavirus vaccine).

The Project is also receiving additional support of $80 million grant from a World Bank administered multi-donor trust fund, Gavi – the Vaccine Alliance, and the United States Agency for International Development. The Bill and Melinda Gates Foundation is also supporting the project through an innovative partial conversion of the IDA credit into a grant upon successful achievement of project objectives.

“Pakistan is grappling with the public health emergency of polio virus transmission. Ensuring strong routine immunization services is the first essential pillar in polio eradication”, says Illango Patchamuthu, World Bank Country Director for Pakistan. “The World Bank and other development partners are working with the Government of Pakistan to strengthen routine immunization services at the critical endgame stage of polio eradication, particularly as Pakistan introduces injectable polio vaccine into its routine schedule”.

The project will incentivize provincial government capacity for rigorous monitoring and effective implementation of its program, including strengthened vaccine logistics, and deploying and expanding qualified technical and managerial personnel.

“Pakistan’s performance in maternal and child health remains weak and inadequate immunization coverage is a major challenge. Childhood immunization against vaccine preventable diseases can help in significant reductions in disability and death”, says Robert Oelrichs, World Bank Task Team Leader of the Project. “The project will establish linkages of the federal and provincial EPI cells with private sector health providers and health-related civil society organizations (CSOs) working in low coverage catchment areas – especially urban slums.”

Children under two years of age in Pakistan are the main beneficiaries of NISP – particularly children belonging to the poorest households in which immunization coverage is lowest. In addition, all children will benefit from strengthened polio and measles interventions.

The credit is financed by IDA, the World Bank’s fund for the poor, with a maturity of 25 years, including a grace period of 5 years.

Buying Down Polio (Partnerships Series No. 2)

By partnering with the World Bank in an innovative way, Rotary has successfully leveraged  its funding for polio eradication, contributing to success towards one year without polio in Nigeria and in Africa. This post, the second in a series on partnerships, innovation, and evaluation, explains how the innovative polio buy-down mechanism has worked.

PIC 3. FROM LEFT: PRESIDENT MUHAMMADU BUHARI VACCINATING HIS THREE MONTHS OLD GRAND-DAUGHTER, ZULEIHA BELLO ABUBAKAR WITH ORAL POLIO VACCINE TO MARK ONE YEAR OF FREE POLIO CASE IN NIGERIA AT THE PRESIDENTIAL VILLA ABUJA ON SATURDAY (25/7/15). WITH HIM ARE: EXECUTIVE DIRECTOR, NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY (NPHCDA) DR ADO MUHAMMAD AND THE INCIDENT MANAGER, POLIO EMERGENCY OPERATION ABUJA CENTRE, DR ANDREW ETSANO 028/JULY2015/ICE/STATE-HOUSE
Nigeria’s President vaccinates his granddaughter – Photo courtesy of Dr. Etsano.

Last month, Africa achieved a key milestone towards polio eradication, with no case of polio observed for a full year. It will still take a few weeks for the World Health Organization to officially certify this milestone, and for the region to be declared polio-free, no polio cases should be observed for a period of three years. Still, tremendous progress towards polio eradication has been accomplished. Just a few years ago, hundreds of cases of polio were observed annually in Nigeria. The country achieved its first full year without polio on July 24, 2015. This will leave only Afghanistan and Pakistan on the list of polio-endemic countries.

As noted in a recent post on the World Bank health blog, achieving one year without polio in Nigeria required persistence and courage. In some areas, professionals and volunteers who led the polio campaigns risked their life: Boko Haram assassinated nine polio vaccinators two years ago in the north of the country. Vaccinators had to rely on “hit and run” tactics to reduce exposure to risk, vaccinating children quickly in the morning and leaving the area by the afternoon. (For an understanding of the role of a wide range of people at the heart of polio eradication (in the case of Afghanistan), see the great slide show provided by the Global Polio Eradication Initiative.)

The polio campaigns also required great effort and creativity from multiple agencies, including through an innovative buy-down mechanism implemented by the World Bank and funded by the Bill and Melinda Gates Foundation, as well as Rotary International and the U.S. Centers for Disease Control via the U.N. Foundation. (The Gates Foundation and Rotary International are the two largest donors worldwide towards polio eradication over the last 30 years.) Partnership with the government of Nigeria, the World Health Organization (WHO), and UNICEF, among others, was also crucial to the success of the campaigns.

How did the polio buy-down mechanism work? The basic idea was for the World Bank to fund polio eradication projects through concessional IDA (International Development Association) loans. In the case of Nigeria, two projects worth $285 million, including additional financing, were implemented over the last dozen years. The projects included clauses that allowed loans to Nigeria to become grants if the country achieved a high level of polio immunization coverage. In other words, if the immunization targets indicated in the loans were achieved and verified independently through in-depth audits, the government would receive grant funding for polio eradication without the need to repay the loans.

For the government of Nigeria, this was potentially a great deal. And for the Gates Foundation and the Rotary Foundation of Rotary International, this was also a pretty good investment. In general, investments towards polio eradication have been shown to be fairly cost-effective. But with the buy-down mechanism, these investments were especially cost-effective.

Due to the concessional nature of IDA loans (long-term zero or low-interest loans which grace repayment periods), for every dollar contributed to the buy-down, the actual amount of resources that could be transferred to the government for the polio campaigns was two times larger. The buy-down funds were transferred by the Gates Foundation and Rotary International (in the case of Rotary in partnership with the United Nations Foundation) to the World Bank at the start of the project, and used to repay the loan at the end of the project if the target immunization rates had been achieved.

Through this buy-down mechanism, the Gates Foundation and Rotary International were able to offset all future loan repayment obligations with a much smaller amount of funding to pay back IDA than the face value of the loans granted to Nigeria. Again, one dollar invested by these private donors generated about $2 for polio eradication in Nigeria, with a similar mechanism in place for Pakistan. The mechanism also had built-in incentives to encourage strong implementation performance by the government of Nigeria since the loans would be transformed into grants only if the specific immunization targets were to be achieved.

At the time of the first buy-down mechanism for polio, then-World Bank President James. D. Wolfensohn stated, “The partnership to buy-down loans to grants on the basis of good performance is an example of the innovative thinking occurring in the private sector and the World Bank about how to increase finances for the fight against global diseases. This financial innovation is bringing the goal of a polio-free world one large step closer to becoming reality.”

Could similar buy-down mechanisms be applied in other areas? That was probably the hope when this innovative mechanism was created for polio a dozen years ago. It seems however that with few exceptions the idea has not yet been replicated much in other development areas, even if it has been mentioned in a number of reports, including in a Results for Development report on education.

A number of conditions have to be met for this type of buy-down mechanism to be successful. But in the case of polio, it has been successful, enabling the Gates Foundations, individual Rotarian donors through the Rotary Foundation, the United Nations Foundation, and the World Bank to achieve higher impact towards polio eradication than would have been the case otherwise.

A brief on polio in Africa and the buy-down mechanism is available here.

This post is reproduced with minor changes from a post published by the author on September 2, 2015 on the World Bank’s Financing for Development blog at http://www.fin4dev.org/.