GPEI-Hard-to-reach areas and long commutes? Challenge accepted

A legion of supporters across neighbourhoods, schools, and households are creating a groundswell of support for one of the most successful and cost-effective health interventions in history: vaccination. These are everyday heroes in Pakistan’s fight against polio.

These thousands of brave individuals are championing polio vaccine within their communities to enlist the majority in the pursuit of protecting the minority — reaching the last 5% of missed children in Pakistan.

One of the major factors that determines whether a child will receive vaccinations is the primary caregiver’s receptiveness to immunization. The decision to vaccinate is a complex interplay of various socio-cultural, religious, and political factors. By educating caregivers and answering their questions, these Vaccine Heroes serve as powerful advocates for vaccination, even creating demand where previously there might have been hesitation. This is where everyday people step in to vouch for vaccination as a basic health right.

Here are some nuanced, powerful, and thought-provoking testimonies on their unwavering belief in reaching every last child:

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Thanks to the unbending resolve and resilience of women health professionals as they go door-to-door across villages and mountains administering vaccine in some of the most marginalized or remote communities, women are truly the backbone of the polio programme at the ground-level. We asked a few of these women about their most daunting and heartening moments in polio, and how they worked through them.

Julia Kimutai—Community Strategy Coordinator Nairobi, Kenya

A day in the life of Julia Kimutai as a Sub-County Community Strategy Coordinator in Nairobi, Kenya. ©WHO EMRO

For Julia Kimutai, a 38-year-old community strategy coordinator in Kenya, educating the public about the importance of vaccines is a constant project. As a specialist in dense urban areas with high rise buildings, Julia knocks on a lot of doors and is often greeted with refusals.

“To convince some mothers is not easy,” she says. “It has never been a smooth ride.”

But where some might just see a campaign-time encounter with skeptical parents as a one-off, Julia sees a long-term project.

“Where we have difficulties is where we double down our efforts to build relationships. We even go back when there is no polio campaign to try to talk with parents, emphasize why vaccination is important and try to do a lot of health education,” she says.

As a woman and as a mother, Julia believes she is uniquely qualified as she can relate, understand and convey the importance of polio vaccines to the numerous apprehensive mothers she meets daily.

“I am a good listener, a good communicator and patient. These tools help me daily as Polio Eradicator and a mother.”

Asha Abdi Dini—District Polio Officer, Banadir, Somalia

A district polio officer with over two decades of experience in Banadir, Somalia, for Asha Abdi Dini, refusals are always heartbreaking. “My worst moment was seeing a family who had three girls and a son. They vaccinated their daughters but refused to allow the boy to take the vaccine. The boy got the polio and the girls survived.”

But Asha takes pride in the challenges she has been able to overcome since joining the polio programme.

“My best moment is seeing the same children I once vaccinated all grown up and bring their own children for vaccinations. It gives me immense hope and happiness,” she says.

Women are on the front lines of polio eradication. ©UNICEF Somalia

Bibi Sharifa—Health Communication Support Officer, Islamabad, Pakistan

A continent away, for 39-year-old Islamabad district health communication support officer, Bibi Sharifa, a big part of the job is demonstrating how women can do difficult work and stand firm in the face of adversity.

“People often think that women are incapable, but they really couldn’t be more wrong. The women on our programme are extraordinary – they are strong, gentle, dedicated, humble, passionate, disciplined and fierce at the same time,” she says. “They are driven by the love of their children and their community, and despite the challenges they face, people should realize that women are like grass, not like trees: where trees can be uprooted by floods, grass can face the brunt of flood easily.”

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Hafiza administering polio vaccine to a young child in Islamabad, Pakistan. © WHO Pakistan/S.Kashif

Like many Pakistani women, Hafiza and Sahiqa start their days in the early morning, when other household members are still asleep. They tackle their domestic chores before beginning their official duties – as polio frontline workers.

“I get up by 5:00 am, if I am to prepare properly for a productive day. I need to manage my home chores before I can set out for my official work. I have to prepare breakfast, lunch, lunch boxes for my children and do the dishes. After that I clean the house and then I have to prepare my kids for school. After sending them to school, I leave for the office around 7:30 am,” Sahiqa explained.

Sahiqa (29) is from Quetta in Balochistan province and Hafiza (22) is from Islamabad. In their careers as Pakistan’s cadre of Lady Health Workers, they deliver house-to-house preventative and curative care to underserved communities, in particular women and children in urban and rural slum areas Locally recruited and community-based, these female health workers are also central to progress against polio in Pakistan’s complex environment.

Across Pakistan, thousands of women do the vital work of immunization in an environment that can be harsh, distressing and even dangerous. They balance this work with the demands of their own children and families, and they put their own needs last.

The women’s official workday starts at 8:00 am and is marked by interactions with the community every day. As part of their work, Lady Health Workers educate women about the benefits of exclusive breastfeeding, on better hygiene practices, supporting the advancement of women and children’s health and wellbeing. They knock on every door of their assigned areas to vaccinate children against polio during frequent immunization campaigns.

Sahiqa from Quetta, Balochistan, is one of thousands of female health workers, constituting 56% of frontline workers in Pakistan. © WHO Pakistan/S.Gull

In Pakistan, women currently make up more than 56% of more than 260 000 frontline polio workers. Having women on the frontlines has been a game changer for polio eradication in Pakistan, given the trusted roles they have in communities and the fact that they are more likely to be allowed to take the crucial step across the thresholds of people’s homes and ensure access for all children to vaccines. Female polio frontline workers including vaccinators, campaign coordinators, supervisors and social mobilizers often work in extremely challenging circumstances to ensure children are protected against polio.

“I remember one chronic refusal family. It was such a difficult task to convince the women of the house to vaccinate their children. We engaged in many discussions and I explained to them that if the polio drops were not beneficial, would I give them to my own kids?

After a lot of convincing, I was able to persuade the women. I was so happy to have managed to convert a chronic refusal case and protect the kids in that house against polio,” Sahiqa said.

Despite multiple challenges, especially working in a conservative province like Balochistan, the health workers remain steadfast and intensely committed when it comes to achieving their goals. They have become creative problem solvers who are motivated by every refusal they convert. The challenges act as fuel and have helped them develop the skills they need to navigate the complexities of the job in this cultural context.

“While performing my job, remaining calm and controlling my emotions are the most difficult skills that I have drawn from these challenges. During this job, I learnt a lot how to avoid taking things personally as this helped me focus on the real objective. With the passage of time, I have realized the importance of maintaining firm boundaries in order to facilitate respectful communication with people,” said Hafiza.

There are different reasons why women in Pakistan make the choice to become polio frontline workers. Some have to support their families and some have to earn money for their studies. Many women take this job because it is the best opportunity to move ahead in life. The defining characteristic of most female polio frontline workers is a passion to serve humanity.

“I feel lucky to have my husband beside me, supporting me in every endeavour. He is also a polio worker and he feels that women have better access to the homes in the communities and can relate to the mothers therefore they have a definite advantage in gaining the trust of the homemakers in the community,” Sahiqa said.

The day is over, but their work is not

The women’s official duty ends with the setting sun, but at home domestic responsibilities await. They have to prepare dinner for the family and then help children complete homework. The idea of eight hours of uninterrupted sleep is a dream for them, but they sleep with the knowledge that they are doing important work, and doing it well.

Hafiza and Sahiqa are individual women, but they are also a reflection of every female worker who is part of the fight against polio. The polio eradication programme would not be where it is today without the contributions of hardworking women dedicated to ending polio.

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Women are the true driving force of the polio programme in Somalia. © WHO Somalia

If you ask the women who work in Somalia’s polio programme why they do what they do, most will tell you they do this to help Somali children, to build a stronger future for Somalia, and to support their own families. Somalia is a complex country with many cultural and institutional challenges for women who work outside the home. Perhaps, as a result, there is a sense of solidarity among the women to pull each other up and work together in the fight against polio.

From the senior member of the polio programme to the district-level polio officer (who chooses to remain anonymous for her own security), and for so many women in between, being part of the polio programme is not just a job, but a way to work together and support each other.

Dr Rehab Kambo—International Focal Point and Head of the Polio Programme, The World Health Organization, Garowe, Somalia

Dr Rehab Kambo wears two hats at The World Health Organization (WHO): International Focal Point and Head of the Polio Programme in the satellite office at Garowe, Puntland state of Somalia. After joining the polio programme, Dr Rehab set out to understand the context she was working in and one of the things she learned was about the strength of Somali women.

Dr Rehab Kambo vaccinating a young child in Somalia. © WHO Somalia

“It is easy not to notice that Somali women are stronger than men in their society, until you spend time with them,” she said.

For Dr Rehab, this realization was driven home on an early assignment. She and a colleague were conducting a surveillance review in a region known as Mudug. Dr Rehab had traveled to Galkacyo by road for eight hours during an active clan conflict, which was no easy feat. Movement was challenging, and the women had to travel with armed escorts. But they were determined, Dr Rehab explains, and they were on a mission.

The two visited transit points at the airport and health facilities to meet with Village Polio Volunteers, who serve the polio eradication initiative at the district level. Upon completing the mission, she and her colleague were elated. Dr Rehab looks back on this as one of the most satisfying – albeit stressful – experiences of her life as a polio eradicator.

Since then, Dr Rehab has taken on the challenge of two roles in one of the most operationally demanding regions in the world. For Dr Rehab inspiration comes easily from the women around her.

“In many instances, they are powerful, independent, and are decision-makers in their families,” said Dr Rehab of the Somali women. Even as a relatively privileged, educated woman, Dr Rehab admits there is a lesson in here for her, and for other women like her.

“Women are so strong, honestly. They can adapt to any role for the good of others,” she said.

Mira A—District Polio Officer, Somalia

Life in Somalia has been extraordinarily difficult since war broke out in 1991, and there is no doubt that it has been harder for women than for men. With an average fertility rate of 6.6 per woman, and high death rates in mothers – one out of every 12 women dies due to pregnancy complications – women are in need of timely and quality health services. A lack of education compounds the problem.

“Despite the challenges, women in Somalia have resiliently stood up to the task and engaged in small-scale businesses over the years to earn a living for their families,” said Mira A, a District Polio Officer in Somalia (we are not using her real name for security reasons).

For Mira A and women like her, taking work outside the home is a way to support not just their families, but themselves – and each other.

“Many women have no time to continue their education or look for other jobs, as they are so busy trying to earn money with their existing means,” she said.

When Mira A looks at the women around her, she sees that education is only part of the answer.

“There is a small sector of women who have managed to earn formal education, but even they do not earn money in most cases. They stay at home and look after their homes and children. Even they need to be empowered, even if it is just to help other women.”

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Polio eradication efforts are as much rooted in the social realities as they are in the technological tools. The success of the Global Polio Eradication Initiative comes down to one simple action: the knock on the door, when the child’s caregiver greets the health worker.

Why do caregivers let vaccinators enter their homes? The caregiver’s decision to vaccinate is influenced by many moving parts: social, cultural, economic, and religious. Women health workers and leaders are able to transcend many of these boundaries as they are not only health workers; they are members of that community – someone’s neighbour, friend, aunt, cousin or grandmother.

Polio-endemic, at-risk, and outbreak countries regularly engage women as health officials in immunization activities, constituting about 68% of the frontline workforce. In Nigeria, 99% of frontline workers are women, followed by 56% in Pakistan and 34% in Afghanistan. But their strength in numbers is not the only reason why women are crucial to polio eradication efforts, they are, in fact, behavioural change agents.

Here’s a look at some of the resilient and inspiring women working to eradicate polio in their communities – in their own words:

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Reposted with permission from Rotary.org

Dr Ujala Nayyar dreams, both figuratively and literally, about a world that is free from polio. Nayyar, the World Health Organization’s surveillance officer in Pakistan’s Punjab province, says she often imagines the outcome of her work in her sleep.

In her waking life, she leads a team of health workers who crisscross Punjab to hunt down every potential incidence of poliovirus, testing sewage and investigating any reports of paralysis that might be polio. Pakistan is one of just two countries that continue to report cases of polio caused by the wild virus. In addition to the challenges of polio surveillance, Nayyar faces substantial gender-related barriers that can hinder her team’s ability to count cases and take environmental samples. From households to security checkpoints, she encounters resistance from men. But her tactic is to push past the barriers with a balance of sensitivity and assertiveness.

“I’m not very polite,” Nayyar says with a chuckle. “We don’t have time to be stopped. Ending polio is urgent and time-sensitive.”

Dr Ujala Nayyar during one of her field visits. © Rotary International

Women are critical in the fight against polio, Nayyar says. About 56% of frontline workers in Pakistan are women. More than 70% of mothers in Pakistan prefer to have women vaccinate their children.

That hasn’t stopped families from slamming doors in health workers’ faces, though. When polio is detected in a community, teams have to make repeated visits to each home to ensure that every child is protected by the vaccine. Multiple vaccinations add to the skepticism and anger that some parents express. It’s an attitude that Nayyar and other health workers deal with daily.

“You can’t react negatively in those situations. It’s important to listen. Our female workers are the best at that,” says Nayyar.

With polio on the verge of eradication, surveillance activities, which, Nayyar calls the “back of polio eradication”, have never been more important.

Q: What exactly does polio surveillance involve?

A: There are two types of surveillance systems. One is surveillance of cases of acute flaccid paralysis (AFP), and the second is environmental surveillance. The surveillance process continues after eradication.

Q: How are you made aware of potential polio cases?

A: There’s a network of reporting sites. They include all the medical facilities, the government, and the hospitals, plus informal health care providers and community leaders. The level of awareness is so high, and our community education has worked so well, that sometimes the parents call us directly.

Dr Ujala Nayyar, the surveillance officer for the World Health Organization in Punjab, Pakistan, navigates through barriers to hunt down cases of polio. © Rotary International.

Q: What happens if evidence of poliovirus is found?

A: In response to cases in humans as well as viruses detected in the environment, we implement three rounds of supplementary immunization campaigns. The scope of our response depends on the epidemiology and our risk assessment.

We look at the drainage systems. Some systems are filtered, but there are also areas that have open drains. We have maps of the sewer systems. We either cover the specific drainage areas or we do an expanded response in a larger area.

Q: What are the special challenges in Pakistan?

A: We have mobile populations that are at high risk, and we have special health camps for these populations. Routine vaccination is every child’s right, but because of poverty and lack of education, many of these people are not accessing these services.

Q: How do you convince people who are skeptical about the polio vaccine?

A: We have community mobilizers who tell people about the benefits of the vaccine. We have made it this far in the program only because of these frontline workers. One issue we are facing right now is that people are tired of vaccination. If a positive environmental sample has been found in the vicinity, then we have to go back three times within a very short time period. Every month you go to their doorstep, you knock on the door. There are times when people throw garbage. It has happened to me. But we do not react. We have to tolerate their anger; we have to listen.

Q: What role does Rotary play in what you do?

A: Whenever I need anything, I call on Rotary. Umbrellas for the teams? Call Rotary. Train tickets? Call Rotary. It’s the longest-running eradication program in the history of public health, but still the support of Rotary is there.

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The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.

Dr Tedros Adhanom Ghebreysus, WHO Director General and Chair Polio Oversight Board, administering polio drops to a young child in Pakistan. WHO/Jinni — Dr Tedros Adhanom Ghebreysus, WHO Director General and Chair Polio Oversight Board, administering polio drops to a young child in Pakistan. © WHO/Jinni

Cornering wild poliovirus

Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.

In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.

Program innovation

The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.

Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.

Lake Chad Polio Task Team wave to polio vaccinators and community members on Ngorerom island, Lake Chad. © Christine McNab/UN Foundation

The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.

Battling circulating vaccine-derived poliovirus

In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.

The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.

In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.

Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.

New policy decisions

At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.

Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.

Comprised of members, advisers, and invited Member States, the 19^th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee. “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.” “We have achieved eradication of a disease once before, with smallpox,” Rees concluded. “The world is a much better place without smallpox. It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”

Six-year old Gafo was the first polio case in Papua New Guinea in decades, which prompted a national emergency and an outbreak response. © WHO/PNG

Spotlight on gender

In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.

The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.

Donor and country commitments

Throughout 2018, political leaders around the world voiced their support for the programme’s efforts, including Prime Minister Trudeau, WHO Director General Dr Tedros, Prime Minister Theresa May, His Highness Sheikh Mohamed bin Zayed Al Nahyan and His Royal Highness Prince Charles. Leaders demonstrated commitment by advocating for a polio-free world at various global events, including the G7, G20, CHOGM, and the annual Rotary Convention.

Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.

Looking ahead: 2019 and beyond

Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.

Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.

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Last month, Afia and her colleagues vaccinated 9.9 million children and educated millions of parents about vaccination across the country. © UNICEF Afghanistan

This is southern Afghanistan. A place characterized by a rich, diverse, but often complex history. Enveloped by mountains, this part of the country has seen years of conflict which have left hospitals under-resourced and health services shattered. Children face many challenges – as well as conflict and poverty, southern Afghanistan has the highest number of polio cases in the world.

In this difficult environment, the virus can only be defeated if every child is vaccinated.

Afia holds a young child who has just received a polio vaccination. The polio eradication programme is one of the biggest female work forces in Afghanistan. © UNICEF Afghanistan

Afia (not her real name), who is nineteen years old, is one of over 70 000 committed polio workers in Afghanistan, supported by WHO and UNICEF. Last month, she and her colleagues vaccinated 9.9 million children and educated thousands of parents about vaccination across the country.

The polio eradication programme comprises one of the biggest female workforces in Afghanistan: a national team, all fighting polio. Some women work as vaccinators, whilst others, like Afia, are mostly engaged in education and social mobilisation efforts. The polio programme gives women culturally-appropriate opportunities to work outside the house and engage in their community, speaking to parents about the safe, effective polio vaccine, and answering their questions. Often, women vaccinators offer other kinds of health advice, including recommendations for good child and maternal health.

To be a good vaccinator and educator, women must be committed to better health for all, with strong communication skills. They must also be organized to ensure that every child is reached during the campaign.

Afia says that if she wasn’t eradicating polio, her parents would expect her to give up her education and get married. Her younger sisters look up to her, excited to work in the polio eradication programme when they are old enough.

Her job is very important to protect all children. Afghanistan is just one of three countries – the others are Nigeria and Pakistan - that have never interrupted poliovirus transmission.

Women can vaccinate children who might otherwise miss out. Culturally, male vaccinators are unable to enter households to administer vaccine, causing difficulties if young children are asleep or playing inside. Their freedom to enter homes and give the vaccine to every child is one reason female polio workers are so critical.

Afia started work at 7 am, and is now walking home ten hours later with a young boy she has just vaccinated. Her purple burka stands out against the sand as she goes home to tell her parents and siblings about her day.

Afia feels positive about the future of polio eradication in Afghanistan: “We have a duty to protect our children, and I won’t stop working until every child is protected.”

Women have a right to participate in all aspects of polio eradication. Removing barriers to women’s full participation at all levels is a key goal for the Global Polio Eradication Initiative (GPEI). To learn more, see the gender section of our website, and read the GPEI ‘Why Women’ Infographic.

Afghanistan is just one of three countries —the others are Nigeria and Pakistan — that have never interrupted poliovirus transmission. © UNICEF Afghanistan

Bella smiles as she vaccinates a small baby against polio – one of hundreds of children she will protect over the course of a campaign. © WHO Somalia

Somalia, which stopped indigenous wild polio in 2002, is currently at risk of circulating vaccine-derived poliovirus type 2, after three viruses were confirmed in the sewage of Banadir province in January 2018. Although no children have been paralysed, WHO and other partners are supporting the local authorities to conduct investigations and risk assessments and to continue outbreak response and disease surveillance.

Underpinning these determined efforts to ensure that every child is vaccinated are local vaccinators and community leaders – nearly all of whom are women.

Bella Yusuf and Mama Ayesha are different personalities, in different stages of their lives, united by one goal – to keep every child in Somalia free from polio. Bella is 29, a mother of four, and a polio vaccinator for the last nine years, fitting her work around childcare and the usual hustle and bustle of family life. Mama Ayesha, whose real name is Asha Abdi Din, is a District Polio Officer. She is named Mama Ayesha for her maternal instincts, which have helped her to persevere and succeed in her pioneering work to improve maternal and child health, campaign for social and cultural change, and provide care for all.

Protecting all young children

Working as part of the December vaccination campaign, which aimed to protect over 700 000 children under five years of age, Bella explains her motivation to be a vaccinator. Taking a well-deserved break whilst supervisors from the Ministry of Health and the World Health Organization check the records of the children so far vaccinated, she looks around at the families waiting in line for drops of polio vaccine.

“I enjoy serving my people. And as a mother, it is my duty to help all children”, she says.

For Mama Ayesha too, the desire to protect Somalia’s young people is a driving force in her work. A real leader, she began her career helping to vaccinate children against smallpox, the last case of which was found in Somalia. Since then, she has personally taken up the fight against female genital mutilation, working to protect every girl-child.

She joined the polio programme in 1998, working to establish Somalia as wild poliovirus free, and ever since to oversee campaigns, and protect against virus re-introduction. In her words, “My office doesn’t close.”

Working in the midst of conflict

The work that Bella and Mama Ayesha carry out is especially critical because Somalia is at a high risk of polio infection. The country suffers from weak health infrastructure, as well as regular population displacement and conflict.

For Bella, that makes keeping children safe through vaccination even more meaningful.

“Through my job I can impact the well-being of my children,” she says. “For every child I vaccinate, I protect a lot more”.

Mama Ayesha echoes those words when she contemplates the difficulties of working in conflict. For most of her life, the historic district where she works, Hamar Weyne, has been affected by recurrent cycles of violence and shelling. With her grown children living abroad, she could easily move to a more peaceful life. But she chooses to stay.

“This is my home, and this is where I am needed. I am here for my team, and all the children.”

“I am the mother of all Somali children. I am just doing my job”. © WHO Somalia

Ongoing determination

Looking up at a picture of her husband, who died many years ago, Mama Ayesha considers the determination and courage that drives her, Bella, and thousands of their fellow health workers to protect every since one of Somalia’s children. Behind her thick wooden desk, she is no less committed than when she began her career. “If I had to do it again it would be my pleasure.”

Bella has a similar professional attitude, combined with the care and technical skill that make her a talented vaccinator. Returning to her stand below a shady tree, she greets the mothers lined up with their children. As she carefully stains the finger of the first small child purple, showing that they have been vaccinated, she grins.

“I am the mother of all Somali children. I am just doing my job”.

Mama Ayesha, a leader of eradication efforts in her district, considers what drives her work. © WHO Somalia

For more stories about women on the frontlines of polio eradication

Over the years, the Polio Eradication Initiative has been a vehicle for the empowerment of Nigerian women economically and socially. In recent times, this positive development has gained more impact with the timely and direct disbursement of funds for payment of vaccination personnel allowances down to grassroots level.

Over 360 000 vaccinators are engaged to support one round of national polio campaigns, and a further 180 000 for a round of sub-national campaigns. Out of these figures, over 80% are in the northern part of Nigeria where 100% of House-to-House teams are females. In addition, 100% of the supervisors are women. Further profiling of personal for all vaccination teams (including fixed post and transit point teams) indicate that 62% of the vaccinators are females. The findings also showed 88% of them have mobile phones for timely alerts and payments.

Interestingly, most of the female vaccinators are pooling their mobile money so they can have a bigger amount to kick-start their small-scale income generation projects.

“I have been able to successfully establish a business from stipends received from polio campaign and now have a source of income. I acquired a shop, bought machines and fabrics and now, I am the local tailor in my community,” Malama Amina Mohammed, a polio vaccinator team supervisor in Zamfara state mentioned.

Touching lives

There is considerable anecdotal evidence from WHO Nigeria Kano, Katsina and Kaduna state field offices that the huge investments by donors and partners have gone beyond polio eradication to impact positively on the lives of women, thereby enhancing equity.

Happy Gabriel is a student at Kaduna Polytechnic. She became a vaccinator three years ago after gaining admission for her diploma course. Polio programme stipends assisted her to concentrate on her studies and helped greatly to buy books and for her upkeep.

Appreciating the stipends received from SIAs, Happy stated, “I am deeply indebted to the polio immunization programme especially the initiative of Mobile money which eliminates delays we hitherto encountered at payment sites and equally engenders transparency.”

Very soon, Ms Gabriel will obtain her Ordinary National Diploma certificate from an accredited Nigerian institution and be gainfully employed even when polio is finally eradicated.

Asiya Ibrahim in Dala local government area of Kano is a widow. She has been a vaccinator for over six years. She lost her husband shortly before joining the polio programme. The stipends received has been helpful to sustain and keep her house together, including the upbringing of her children such as schooling, feeding and clothing.

With the frequency of the polio campaigns in the north, stipends received after each round cushioned the effect of losing her husband as she is always engaged in some form of activity.

Direct Disbursement Mechanism

Prior to 2004, operational funds to support SIAs in Nigeria were deposited by partners in a central dedicated account managed by the central government agency responsible for disbursement of the funds to vaccination teams. This mechanism faced a number of challenges including under-payment or non-payment of end-beneficiaries, delays in payment and retirement and inadequate documentation.

WHO conducted a risk assessment in 2013 and then established the Direct Disbursement Mechanism; an innovation that is considered a best practice and emulated by wide range of stakeholders.

With the innovation, the polio programme has helped to build up lives of vulnerable and economically disadvantaged personnel, especially those of women especially in poverty-stricken villages of northern Nigeria. The allowances after each round of SIAs have made them responsible to their immediate families and environment.

Polio interruption impossible without women

While monitoring the February 2017 round of SIAs in Kano, Dr Wondi Alemu, the WHO Country Representative, underscored the important role of female vaccinators who “are doing a marvelous job of fighting polio by negotiating and engaging with parents even when on transit. Without these women, the fight against polio will not be completed in Nigeria. The mothers trust them as they use techniques, including gestures and understandable language to convey much more meaning that easily persuades erstwhile resistant caregivers”.

Dr Alemu strongly feels that one lesson learnt from PEI is that the success of any public health intervention in Nigeria, especially in the north, hinge on the active participation of women who have empathy and patience to deal with diverse human emotions.

Additionally, through numerous training schedules and other activities organized by WHO and other GPEI partners preceding SIAs round, women’s skills have been empowered. Such skills as interpersonal communications skills, including negotiations have immensely contributed to resolving non-compliance to the oral polio vaccine among difficult to convince populations in northern Nigeria.