Political Commitment & OWNERSHIP for PEI/EPI

1. Political Commitment & OWNERSHIP for PEI/EPI Punjab-2008

2. Punjab Demographic background: > half the population of Pakistan. Projected population for 2008 ~ 96 million. wide diversity of geographical, cultural characteristics, and literacy rates. Political set up: Established political set up and civil administration. Decentralized to the district level Unique challenge: 2 managers in each district (EDO/ DoH) - no clear TOR, may lead to conflicting interest .

3. Political commitment Leaders to use their personal involvement, power, and influence, to ensure that PEI / EPI is a top priority and extend their full support to achieve polio eradication Essential: Currently ..to: Ensure that they continue extending their support to PEI for highest quality campaign activities Guard against false sense of over confidence. After being polio free..to: Keep the interest ,commitment and motivation when polio is not visible as a public health problem Sustain high vaccination coverage Sustain rigorous AFP surveillance.

4. Issues took into consideration… Multiple Centers of influence: Federal: slim influence at the provincial level. Provincial: (policy making and planning, little involvement in implementation and monitoring at district level) District: the main operational units/ key players….totally independent Political / establishment: Nazim, DCO Managerial: EDO, DSV, DoH, DDHOs, Others: Unions. Religious leaders (different religious set up almost in each district) Community leaders / opinion leaders NGOs /CBOs

5. Issues took into consideration..(cont) • Types of influential powers: • Formal (official- authorized influence) • Informal (unofficial - un-authorized influence) These multiple centers of influence, sometimes competing with each other creating power gap, represents a real challenge to the issue of political commitment.

6. Governor/CM/CS – Minister of Health Frequent NIDs- News articles fading interest Competing priorities (H.R) Conflicts (in-built). Competing priorities Less oversight by provincial authorities Rapid turn over Single line budget Sec. Health /DG/DHS (EPI) DCO \ Nazim EDO(H)/DOH Still to be further motivated • Rumors • Local Values • Traditions • Religious misbelieves DDHOs/Tehsil Nazims • Local Politics • Departmental Associations • Fatigue Vaccination Teams/LHWs Community

7. Capacity building, Monitoring, supportive supervision , incentives Sustained social mobilization

8. Who to address Provincial leadership: Political leaders and civil administration (Governor, Chief Minister, Health Minister, Chief Secretary, Secretary Health, DG, EPI manager). District decision makers / opinion leaders/others: Political and civil administration Opinion leaders : (religious, political, media, line depts) Traditional healers, private practitioners Community & Community leaders NGOs / Unions Field staff (better monitoring , supervision and support)

9. Building/Maintaining Political Commitment Trust building and Mutual respect Avoid contradicting messages…Joint management team approach. Avoid bypassing immediate officials Avoid creating parallel system Re-enforce ownership continuously Low profile constant communication about polio\EPI Maximize utilization of the support of : ISB, EMRO, H.Q. Use the appropriate local channels of communication Maximize utilization of all communication channels. Appropriate approach for specific issues. APPROACHES

10. meetings (the most effective tool) Pre-campaign meeting: Chaired by H.M / S.H District Polio Eradication committee meeting: Chaired by DCO/Nazim Monthly Provincial Surveillance review meeting: Monthly District Surveillance Committee Meeting: Expert Review Committee meeting (ERC) Evening meetings (during campaign days): Regular feed back. Regular visits and meetings with district level political leaders. High profile visits Recognition (polio free flags, certificates..etc) Telephone calls from program leaders (EMRO/ISB) to high district politicians in special circumstances. Tools

11. Different Approaches for leaders at different levels Chief Minister Governor Health Minister Very busy and direct approach difficult. High profile visits very helpful Support is through NID inauguration and communication to CS and local government High profile visits Regular feed back Frequently inaugurate NID Periodic direct approach Regular feed back Frequently inaugurates NID Chairs pre campaign meetings

12. Chief Minister, Health Minister and Secretary Health inaugurating NID

14. Different Approaches for leaders at different levels(cont.) Chief Secretary Secretary Health Invitation to global meeting at H.Q. High profile visits Periodic direct communication and feedback Passes clear instruction to local government to ensure their involvement Instructions to Police department for their maximum support and involvement in NIDs. Periodic direct approach and feedback Chairs NID campaign meetings Gives clear instructions to health department to ensure quality NID implementation Personal participation

18. Cheif Secretary chairs pre campaign meeting with all DCOs / EDOs

23. Different Approaches for Different Officials (cont.) Nazim DCO Regular direct communication and telephone communication DCCO to call all UC Nazims before, during and after the campaign Inaugurates the NID in his district Passes clear instruction to district government officials Public statements for media Regular direct communication and telephone communication Leading PEI activities in the district Chairs DPEC meetings Gives clear guidance to health department to ensure quality NID implementation in the district Allocate required resources from other line departments

24. Polio Walk in the district WITH INNOVATIVE STYLES & PARTICIPATION FROM ALL SECTORS

25. Advocacy Meeting with Mosque Imams & Religious Leaders from all districts

27. Different Approaches for Different Officials (cont.) EDO DOH Regular direct communication with STC Periodic meetings/telephone calls at provincial level Pre campaign meeting chaired by H.M, S.H and DG Health. Regular direct communication with STC and SO Fully involved in training, monitoring for PEI Supervises district EPI staff to ensure quality NID implementation in the district

28. EVENING MEETINGS IN THE DISTRICT.

29. SPECIAL ADVOCACY INTERVENTIONS TO OVERCOME SPECIFIC CHALLENGES

30. Maintaining Commitment in Difficult Situations Outbreaks Security problematic areas Refusals Anti vaccine rumors. Special issues: accident to one vaccinator (important to appreciate the workers and also to maintain the commitment) Unexplained change of attitudes of political leader. Competing programs

31. ADVOCACY MEETING EX.Chief Secretary’s Meeting with DCOs of HR Districts

33. Security Compromised Areas. Activities Done. • Advocacy meetings with local notables / tribal elders through district government. • Social mobilization through local teams moving house to house-CCSPs.

34. Monitoring Political Commitment Quantifiable indicators: Statements made by leaders CS to chair special meetings with DCOs Letters from CS to DCOs Participation of district decision makers in the provincial review/preparatory meetings Leading Polio walks & inaugurations District Polio Eradication Committee meetings DCO\Nazim personally involved & allocate resources Mosque announcements Refusals

35. Monitoring Political Commitment cont’d Subjective indicators: Accessibility to decision makers How leaders are knowledgeable about polio Response of leaders to rumors Response of leaders to the recommendations Composite indicator: Attempt to use all the aspects of political commitment collectively using the judgment of the field staff.

36. Emerging challenges Fatigue: Increasing fatigue at all levels A real problem when it affects a high level leader Competing priorities: Punjab Health Sector Reform Program MCH programmes Other preventive programmes (T.B dots, Roll back malaria, anti hepatitis programme, avian flue…etc) Increasing anti vaccine propaganda Enhanced resistance among medical community Polio is not seen as a major public health problem Fading interest among some key decision makers (unexplained change of attitude)

37. What is next Re enforce high level advocacy Involve PEI staff to assist in other priority public health problems Concrete scientific approaches to face the anti vaccine propaganda (proactive standardized message at different levels) Continue maintaining good performance of field staff Continue maximizing utilization of S.M tools

38. Ownership level 2008 • Government of Punjab maintained high level of program ownership • Rapid immediate very high quality case response. 2/3 of the operational costs to WHO and 1/3 managed within the district local resources. • Vaccination of nomads in 6 districts in response to cases in NWFP and Balochistan: all costs managed within local district resources. • In spite of the existing political \ security situation C.M, H.M, and S.H inaugurated Jan 2008 NID

41. We always remember…. Maintaining political commitment and ownership is a continuous cumulative process Political leadership has brought Punjab (and Pakistan) to the brink of polio eradication. But if this leadership and commitment weakens now, we may not achieve the goal of eradication. Maintaining political commitment, interest and ownership in the coming period is of prime importance to improve routine EPI and guard against the impact of importation of wild polio virus….

42. THANK YOU