The contribution of the polio eradication initiative on the operations and outcomes of non-polio public health programs: a survey of programs in the African region

Introduction The effect of the Global polio eradication initiative (PEI) on public health programs beyond polio is widely debated. PEI contribution to other health programs has been assessed from the perspective of polio-funded personnel, which may introduce bias as PEI staff are probably more likely to show that they have benefited of other programs. We set out to identify and document how public health programs have benefited from the public health capacity that was provided at the country level as part of the PEI program in a systematic and standardized manner. Methods Between July and November 2017, we conducted a mixed-methods cross-sectional study, which combined two methods: a multi-country quantitative survey and a qualitative study. We created a self-administered electronic multi-lingual questionnaire in English, French and Portuguese. The qualitative study, which followed an interim analysis of the quantitative survey, comprised interviews with national and subnational level staff in a few countries. Results A total of 127 public health workers from 43 of the 47 countries in the African WHO Region responded online. Most of the respondents 56/127 (42.7%) belonged to the immunization sector and 51/127 (38.9%) belonged to the emergencies and outbreaks sector. Respondents who identified themselves with the immunization (50/64 (78%)) and maternal health program (64/82 (78%)) reported the highest level of greatly benefiting from PEI resources. A total of 78/103 (76%) respondents rated PEI’s contribution data management system to their program very high and high. Of the 127 respondents, the majority 91 (71.6%) reported that the withdrawal of PEI resources would result in a weakening of surveillance for other diseases; 88 (62.9%) reported that there would be inadequate resources to carry out planned activities and 80 (62.9%) reported that there would be poor logistics and transport for implementation of activities. Cameroon, DRC, Nigeria and Uganda participated in the qualitative study. Each country had between 7-8 key informants from the national and sub-national level for a total of 31 key informants. Polio funds and other PEI resources have supported various activities in the ministries of health of the four countries especially IDSR, data management, laboratories and development of the public health workforce. Respondents believed that the infrastructure and processes that PEI has created need to be maintained, along with the workforce and they believed that this was an essential role of their governments with support from the partners. Conclusion There is a high awareness of the PEI program in all the countries and at all levels which should be leveraged into improving other child survival activities for example routine immunizations. Future large-scale programs of this nature should be designed to benefit other public health programs beyond the specific program. The public health workforce, surveillance development, data management and laboratory strengthening that have been developed by PEI need to be maintained.


Introduction
The effect of the Global polio eradication initiative (PEI) on public health programs beyond polio is widely debated [1][2][3][4]. However, PEI happens to be one of the only programs that reach vulnerable children in hard to reach areas multiple times a year; indeed many programs have used that reach to tack on several public health interventions [5]. The public health effects of PEI probably differ from the context where there is multiple supplemental immunization activities (SIAs) and national and subnational immunization days (NIDs) to those where polio was interrupted long ago [2,6]. PEI contribution to other health programs has been assessed from the perspective of polio-funded personnel, which may introduce bias as PEI staff are probably more likely to show that they have benefited other programs. An assessment of what the other programs can define or view as the benefit PEI provided to them is likely to avoid that bias. It is also not clear that other public health programs are aware of what will happen when PEI ends, and there is limited literature that defines this, based on robust scientific methods.
Current documentation evaluates how PEI has contributed to programs that are mainly immunization-related -for example in supporting public health surveillance outcomes and supporting routine immunization (RI) and new vaccine introductions [7]. The support and enabling functions (i.e., training, supervision, coordination, communication, other managerial support) of PEI have not been adequately assessed. It is also likely that PEI contributes a lot to operations of WHO Country Offices (WCO) and public health programs in ministries of health (MOH) [8]. An assessment of what benefits programs have received from PEI from the perspective of non-polio public health workers and disease control programs may provide a measure of the gap that will exist when PEI funding ends [9]. It will also help these programs plan for that gap. Additionally, there may be unknown benefits from PEI funds that other programs have obtained. Conversely, PEI may believe that it is benefiting programs that do not perceive this benefit themselves. Based on the above we set out to identify and document how public health programs have benefited from the public health capacity that was provided at the country level as part of the PEI program in a systematic and standardized manner. It is expected that the results of this study will guide the African region on how to utilize the public health capacity from large vertical programs and will also provide lessons to the PEI legacy in the African Region.
countries provided case studies that allowed the study to obtain granular and explanatory information from the sub-national level.

Ethical considerations
The study obtained clearance from the WHO-AFRO Ethical Review Committee. Participants' confidentiality was protected; their contributions were not biased, altered or misrepresented. The identities of participants in the study were protected in the quantitative and qualitative component of the mixed methods study. Respondents who identified themselves with the immunization (50/64 (78%)) and maternal health program (64/82 (78%)) reported the highest level of greatly benefiting from PEI resources ( Of the 127 respondents, the majority of 114 (89.1%) reported that country governments at all levels had the responsibility to sustain existing polio funded structures when the PEI funding ended (Table   7). Slightly over half of the respondents (74, 57.8% and 73, 57%) felt that global partners and donors or other public health program should sustain polio funded structures when the PEI funds end.

Results from the qualitative study
Cameroon, DRC, Nigeria and Uganda participated in the qualitative study. Each country had between 7-8 key informants from the national and subnational level for a total of 31 key informants. Polio that the infrastructures and processes that PEI has created need to be maintained, along with the workforce and they believed that this was an essential role of their governments with support from the partners. All respondents at all levels were aware that PEI resources were ending soon and they believed that the end of these resources would leave significant gaps in public health activities and this needs adequate planning.

Discussion
Our study, which is the first ever African continent-wide look at what non-polio programs believe is the benefit from PEI, showed interesting but consistent results between the quantitative survey and the qualitative study. There is a high level of awareness of the PEI program, and most public health workers interviewed had been involved in PEI in one way or another, which shows the considerable effort towards public health capacity development that PEI implemented. Furthermore, IDSR which is the primary strategy that the continent uses for public health surveillance and response, as well as IHR (International health regulation), would not be where it is now without PEI's investment [10].
The PEI program over the years of its existence has provided the largest resources to any public health intervention on the African continent [11]. Because the enduring success of the gains against polio depends on maintaining a more robust public health system that can conduct surveillance for any new polio cases, immunize children against polio and other childhood illnesses, and respond to polio and other disease outbreaks, it is imperative that the public health system that PEI supported is maintained. In a previous mixed methods study on the impact of PEI on primary health care, there was some evidence of PEI's support for surveillance and the public health workforce [2]. However, support for surveillance was limited in Nigeria one of the countries that were envolved in this study. In this study, there was a significant evidence that PEI has felt to support other public health programs from the perspective of those programs. Nigeria relied heavily on its PEI program resources when responding to the 2014 Ebola Virus Disease outbreak, and has continued to rely on PEI for aspects of IDSR [12, 13].
One theme from the study is the need to maintain what the public health activities that were implemented by PEI after the PEI resources are exhausted. Most respondents believed that there would be public health disruptions when the funding comes to an end. How this will happen was not clear to the respondents, but they believed that this should be led by the member States, each using the different health partnerships and resources to maintain essential activities that were supported by PEI. One clear adjacency is routine immunization which paradoxically is at low levels in some countries that have done well in PEI-strategies to leverage PEI before it ends to launch more commitment to routine immunization and maternal and child health programs need to be implemented as soon as possible; if this is successful, this will be one legacy for PEI [4].
Our study relied on recalling events that could have occurred in the past especially in countries where polio has now been eliminated; this may have led to a form of recall bias. Also, whereas the quantitative survey had a high response rate, not everybody responded, and it is therefore possible that those who responded have different opinions from those who did not respond. We also sought for but did not obtain data from the WHO Country Offices of the four countries that were included in the qualitative study and therefore there are no results on corporate support of PEI activities or the role of PEI resources in supporting WHO Country Offices operations. However, using mixed methods study allowed for triangulation of the information, particularly in obtaining subnational level public health professionals opinions, enriches the information from the multi-country survey which had national level staff for the most part.
The general objective of the study was to identify and document how public health programs have benefited from the public health capacity that was provided at the country level as part of the PEI program in a systematic and standardized manner. It is expected that the results of this mixed methods study will guide the African region on how to utilize the public health capacity from large vertical programs and will also provide lessons to the PEI legacy in the African Region.
The overall conclusions from the study are the following. Over 150 public health personnel were involved in the mixed methods study, with 42 countries in the quantitative and four in the qualitative study. Almost all the respondents in the mixed methods study were aware of the polio program and the majority were involved in various PEI activities. The commonest PEI activities they were engaged in were SIAs and surveillance. Respondents strongly agreed or agreed that PEI resources were involved in many public health functions. The most frequently reported benefits from PEI by the respondents were networks and processes of surveillance, a skilled workforce, data management and finances. Most respondents reported that the PEI program had supported their work with resources and that PEI was largely integrated with their activities.
Respondents indicated that the highest ranking of contributions of PEI was to data management, a skilled workforce, processes for surveillance and the laboratory network. The lowest contribution was attributed to the Emergency Operation Centers (EOCs).
Respondents believed that the infrastructure and operations that PEI has created need to be maintained, along with the workforce and they believed that this was an essential role of their governments with support from the partners. All respondents at all levels were aware that PEI resources were ending soon, and they believed that the end of these resources would leave significant gaps in public health activities and this need to be planned for appropriately.

Conclusion
We conclude and recommend the following: there is a high

Authors' contributions
All authors have contributed to this work and all of them have read and agreed to the final manuscript.