IN A NUTSHELL Author's notePakistan, despite decades of focused eradication efforts, remains one of the few countries where polio continues to threaten children’s futures. As we assess progress toward eradication by 2050, this article offers a realistic and evidence-based review of the innovations introduced and the ground-level challenges that persist. While digital tools, better vaccines, and microplanning have evolved, a critical human factor is often neglected—the grossly inadequate incentives for frontline workers, supervisors, and Union Council staff, who are central to campaign execution. Low per diems, multiple job burdens, weak accountability, lack of third-party verification, and an uncommitted EPI infrastructure all contribute to persistent virus transmission. Surveillance gaps, mobile populations, refusals, and environmental contamination continue to keep Pakistan in a cycle of near-eradication followed by resurgence. The article urges a structural reset—prioritizing people over systems—to make true eradication a reality by 2050
Healthcare System, CHIP Training and Consulting
Quetta, Balochistan Pakistan
Polio Eradication in Pakistan by 2050
Innovations, Gaps, and the Forgotten Human Factor
Introduction: Where We Stand in 2050
Polio was once nearly eradicated in Pakistan, with zero reported cases in select years. However, by 2050, it is clear that the virus has not been eliminated sustainably. Despite all the tools available—GPS tracking, digital microplans, biometric attendance, and live dashboards—the program still falters due to deep-rooted human resource and incentive issues. This review aims to critically analyze what has worked, what has not, and what needs to change permanently.
The Backbone Under Strain: Frontline Workers
Frontline workers (vaccinators) are the face of the campaign, knocking on doors, facing refusals, traveling long distances, and vaccinating millions of children each month. However, their role is dangerously undervalued:
- Per diems are as low as Rs. 500–800 per day, which does not match inflation or transportation costs.
- Many vaccinators have been part of the campaign for over a decade but remain on temporary contracts, with no job security, benefits, or promotion path.
- To survive, they work multiple jobs—as domestic help, schoolteachers, or in local markets—causing fatigue and divided attention during campaigns.
- Demoralization is rampant. Many feel they are “used only for polio,” with no support for long-term health career development.
🔴 Recommendation: Frontline workers must be paid at least a living wage, given official recognition, and enrolled in formal health workforce pathways.
Supervisors: Multi-tasking Without Recognition
Supervisors (Area In-Charges or UC-level monitors) are expected to oversee 20–25 teams, ensure data accuracy, resolve refusals, report in real-time, and submit daily activity reports. However:
- Their incentives are barely Rs. 1,200–1,500 per day, while their responsibilities are disproportionately high.
- Many are working as teachers or in private jobs simultaneously, with supervision conducted “on the phone” or “via WhatsApp” rather than on-site.
- There is no structured training or certification, despite the program demanding professional-level data handling and team management.
- Supervisors face blame for failures, but rarely receive appreciation for improved coverage or breakthrough results in refusal areas.
🟡 Recommendation: Supervisors must receive salary-based contracts, fuel allowances, performance bonuses, and leadership training to remain committed and accountable.
Union Council Staff: The Neglected Core
Union Council Medical Officers (UCMOs) and UC Polio Officers (UCPOs) are responsible for the entire microplanning, coordination, and logistics chain in their areas. But:
- Their monthly incentives are often as low as Rs. 15,000–20,000, which does not reflect their workload.
- They are required to coordinate with multiple stakeholders (DHOs, NGOs, WHO, EOC, community leaders), yet often operate without proper offices or transport.
- Many UCMOs prefer to focus on private practice or NGO consultancy work where earnings are better, leaving polio responsibilities neglected.
- Frequent turnover and non-permanent positions affect institutional memory and long-term planning.
🟠 Recommendation: Union Council-level staff should be moved to full-time, salaried positions, with career incentives tied to performance in both polio and broader immunisation goals.
Weak Surveillance: The Invisible Failure
Surveillance is the foundation of polio eradication. Unfortunately, surveillance officers and assistants are often:
- Untrained or minimally trained, relying on outdated tools.
- Not motivated to conduct community-based AFP case investigations.
- Under pressure to show high performance, leading to inflated or delayed reports.
This weak surveillance results in: – Late detection of virus transmission. – Silent circulation in areas assumed to be “cleared.” – Positive environmental samples being dismissed without credible response, particularly in areas with large migrant and mobile populations.
⚠️ Note: Poor staff commitment directly weakens the surveillance framework. Without human-centered reforms, data reliability will remain questionable.
Migrants, Mobility, and Environmental Risk
Even in districts with 95%+ reported coverage, environmental samples show poliovirus presence—mainly due to:
- Underserved mobile groups: Afghan refugees, nomadic tribes, brick kiln workers, and seasonal migrants.
- No long-term inclusion strategy: These populations are still not part of EPI routine coverage.
- Transit teams are underpaid, unmotivated, and lack multilingual skills to interact with mobile families.
Without engaging these hard-to-reach populations, polio continues to travel silently across provincial and district borders.
No Third Party, No Trust
Campaigns are still reported as “successful” even when ground teams know the reality is otherwise. This is because:
- Internal monitoring is politically and managerially influenced.
- There is no independent body to verify data, assess staff honesty, or analyze refusal quality.
- This leads to false assurance, misdirected resources, and continued transmission.
🔭 Solution: Establishing an independent third-party monitoring system, possibly at the provincial level, is critical for unbiased feedback and accountability.
Community Trust and Communication Failures
Even after decades, refusal remains a leading challenge. This is due to:
- Repeated, one-way communication: “Vaccinate or else” has replaced respectful dialogue.
- No incentives or visible benefits to compliant families.
- Lack of health education and follow-up by trained female social mobilizers.
Community engagement needs to evolve from campaign messaging to genuine public health conversations.
Incentive Policy Failures: A Root Cause, Not a Side Issue
Despite the billions spent on polio eradication in Pakistan since 1988, the program has consistently failed to design a sustainable and fair incentive system for its ground-level workforce. This single failure has led to a chain of consequences:
❌ Short-Term Fixes, Long-Term Demoralization
- Per diems are still based on decades-old formulas.
- No annual revision mechanisms.
- Temporary hiring creates insecurity and weak motivation.
⚖️ Inequity Within the System
- Same per diem for lowland, urban, and highland, rural workers.
- No hardship allowance for conflict-prone zones.
📉 Consequences:
- Poor morale, high turnover, fake reports, and missed settlements.
✅ Long-Term Solution: Introduce a tiered, performance-based incentive policy adjusted for geography, workload, and years of service.
Comparative Case Study: Lessons from Nigeria
Nigeria was declared polio-free in 2020. Key strategies included: – Fixed stipends, not fluctuating per diems. – Local government ownership of staff payment and monitoring. – Full-time, trained, and identified frontline staff.
Pakistan can learn from this model by building trust, stability, and responsibility into the system.
Sustainability Crisis: Can We Keep Doing Campaigns Forever?
Pakistan continues to run 10–12 campaigns per year, leading to: – Community fatigue and resistance. – Routine immunisation being neglected. – Huge operational costs without long-term benefit.
🛍️ Future Focus: Transition from vertical campaigns to integrated, routine-based health delivery.
Vision 2050: A Realistic Roadmap for Pakistan
✅ 1. Revamp Incentives
- Living wages, regular reviews, hardship allowances.
✅ 2. Integrate Workers into Health System
- Absorb into EPI, nutrition, maternal-child health services.
✅ 3. Independent Monitoring
- Neutral oversight with real-time and community-level checks.
✅ 4. Integrated Campaigns
- Bundle services (polio, deworming, Vitamin A, etc.).
✅ 5. Build Trust Locally
- Engage imams, elders, teachers, and female mobilizers.
✅ 6. Focus on High-Risk Populations
- Mobile health vans, transit teams, and culturally competent outreach.
Conclusion: It’s Not a Vaccine Problem—It’s a System Problem
By 2050, Pakistan has the technology, the funds, and the tools. But polio will not end until the system values the people who deliver the vaccine. Frontline workers, overburdened supervisors, and overlooked UC staff are not just implementers; they are the foundation. The eradication of polio demands not just injections but investment in human dignity, fairness, and long-term vision.
