The impact of polio eradication on routine immunization and primary health care: a mixed-methods study

Abstract

Background: After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC).

Methods: Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review.

Results: Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year.

Conclusions: Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

Keywords: eradication; health systems; poliomyelitis; routine immunization.

Figure 1.

Study hypotheses. Abbreviations: PHC, primary healthcare; RI, routine immunization.

Figure 2.

Qualitative case studies.

Figure 3.

Association between the onset of polio eradication campaigns and diphtheria-tetanus-pertussis (DTP3) vaccine coverage from 2 different sources, the World Health Organization (WHO; left side) and the Institute for Health Metrics and Evaluation (IHME; middle), and attended birth coverage, from the World Bank's World Development Indicators (right side). Each line depicts the predicted values from regression models fit to restricted cubic splines in the presence of covariates. All additional covariates were set at median values. Lines indicate quintiles of initial values of coverage (at time 0), showing that the change in coverage over time depends on the initial coverage.

Figure 4.

Association between polio eradication campaign intensity and diphtheria-tetanus-pertussis vaccine coverage (data are from the Institute for Health Metrics and Evaluation, IHME; left side) and on attended birth coverage (right side). Thick lines indicate different levels of initial coverage (first quartile, median, and third quartile). Dotted lines represent 95% confidence intervals. Partial effects for both dependent variables were very similar for an alternate measure of campaign intensity, percentage of population targeted (not shown). The very wide confidence intervals in the right panel for higher initial values of coverage (dot-dash and solid lines) indicate a lack of observations at high levels of campaign intensity for countries. This selection bias complicates interpretation of this analysis.

Figure 5.

Results of qualitative analysis. Please refer to the end of the Supplementary Materials for definitions of the categories used in the figure.