Adarsh Misra, IAS, AGMUT
Polio Eradication and elimination programme: How to use PMO when a State delays implementation.
This article is about how to use PMO when implementing a Concurrent List Programme. Health being a Concurrent List Programme was always a difficult programme to implement to one’s satisfaction as performance would invariably lag in some States.
In 1995 when I first conceived and started the Pulse Polio Programme, I was Joint Secretary Family Welfare in charge of Immunization, Reproductive Health and Information Education and Communication
First, I place below the dimensions of the Pulse Polio program. The aim at this stage was to eradicate the disease and thus reduce the burden of morbidity in the country.
The challenge was indeed large as the only other comparable exercise would be the holding of Elections, which too, have three to five phases for implementation. The exercise for Pulse Polio was for simultaneous delivery of polio drops on the same day everywhere in the country, to all infants 0-3 years of age and to carry this out in villages, towns, cities, including trains, bus stations, airports and border areas. Tribal interiors and troubled areas like J&K and Assam had special arrangements made for them.
The Pulse Polio Eradication programme was designed with active support from WHO, UNICEF, DFID, USAID and many other bilateral and international aid agencies.
Non-government organisations like Rotary and Lions stood by our side in the tough moments of delivery of the programme. The firm support in monetary terms from Finance Ministry and the political commitment for the programme was secured from PMO. At this stage after calculating total Aid in kind being made available and the residual cost of the estimates of what India would bear were only around Rs. 50,000 crores. As the programme continued for many decades, inevitably the costs escalated over time, even though the drugs were manufactured in Indian laboratories. (After a decade and a half, it was decided to go for eradication and elimination of the disease thus demanding a much more minute coverage in areas constantly reporting cases of polio. Besides till the world is free of this disease the programme had to continue to be implemented.)
To launch the programme, the logistics included:
- Assured supply of vaccine from any of the four international suppliers. Here the Rotarians through their international Chapters were of tremendous help, including getting the rates dropped to make it easier for Aid agencies to buy thus making it possible to carry out the program.
- Tying up other essentials: UNICEF committed for provision of other essentials for the delivery and other agencies shared the remaining projected costs.
- Obtaining the cooperation of all State Governments and Health Departments.
- Coordinating and tying up supply points for delivery of Vaccine State wise and necessary tie ups with transport both air and road/train.
- Delivery of training till field level for team building, an essential skill for delivery at multiple points simultaneously on a single day. Teams were drawn from teachers, anganwadi workers, Public Health Centre Staff and patwaris and/or any local official available from any Department. Latter’s from Cabinet Secretary to all departments secured this cooperation.
- A Step by Step Guide for all participants, particularly states was necessary. An Operational Book was printed which provided the basic information on the essential steps.
- Every stage was categorised and actions were worked out.
- The need for setting up of Cold Chains for receipt of vaccines and then transfer to next level then till field level. The same Cold Chain also acted in reverse for returning samples from infants who had caught Acute Flaccid Paralyses as a result of being vaccinated.
- Massive Media publicity and Information Education and Communication efforts were necessary involving Bollywood stars, State level Movie Stars, cricketers, sportspersons, literatures of repute and the timely showing of short clips on prime-time TV and radio and in press. Bus hoardings, wall hoardings, etc., helped to further augment the message.
The list is endless and the above is not exhaustive but spells out the hours and hours of work put in by the team in Ministry of Health, Department of Family Welfare from the desks dealing with Immunization and IEC and State Governments, NGOs, Aid Agencies and concerned Ministries.
The reason why I at all mention some of the tasks is to illustrate how interdependent every task and its completion were to the success of the programme.
It may be recalled that Health is a Concurrent List subject and in our federal structure no programme can be successful unless every state commits to its implementation and makes provision for the same in their budgets.
To obtain the willing support from the States, a conference of Chief Ministers of all states was convened and addressed by the then Union Health and Family Welfare Minister. So eloquent were his words that by tea time we had full support from all States.
Nonetheless, I just could not get the cold chain operational in Bihar. We tried everything, deputing officers, sending representatives from Aid agencies, speaking to Chief Secretary, getting Cabinet Secretary to write to State Government, but matters stayed at standstill and we were getting dangerously close to the date of the first polio drops being delivered.
Finally, with permission of my Secretary, I approached PMO and with active intervention of PM we suddenly had the programme on full go in Bihar. We could not keep up pace with the demand generated after the incumbent Chief Minister went on TV and asked all Bihari children to report for immunization!
The Pulse Polio programme was to cover in the first phase only 0-3 year olds. But such was his command over the people in Bihar that a few words from him on TV galvanized the entire state: the cold chain was completed in record time; the trainings of the teams had already been done and on the day of the Pulse the teams had to deal with children up to 8- 9 years of age also. We had to rush vaccines from West Bengal and Orissa to make good the shortfalls in Bihar and send fresh supplies to these States on special flights so as not to disrupt delivery of the Pulse on same day.
The first drops were administered by President of India and Prime Minister of India leading to massive media coverage, which in turn led to larger coverage in the second round. We covered 95 million infants in the first round in December 1995 and 110 million in January 1996 in the second round.
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