Twenty-nine interviews were conducted among health workers residing in Abuja, Kano, Nasarawa, and Oyo states (see Table 1 for details). The average duration of the interviews was 70 min. Almost all respondents (26 of the 29) were engaged in polio program activities at the national or subnational levels. Most of the respondents (18 of the 29) were working with government organizations at the three tiers of health care delivery and 11 of the 29 respondents were working with international organizations.
Only one respondent identified to have primarily worked for the Polio Eradication Initiative throughout his career while other respondents have worked with other health programs including the routine immunization program in the course of their careers. Examples of routine immunization activities the respondents participated in included supplemental immunization activities such as measles campaigns, yellow fever, and Hepatitis B vaccinations. Other programs mentioned were HIV/AIDS, Tuberculosis control, and Maternal, and Child Health programs. Some GPEI partner organizations respondents indicated that they occasionally participated as consultants in other health programs.
Health workers' perception of the benefits and challenges of combining polio eradication activities with routine immunization programs and other health programs
The respondents in this study stated that working within the polio program has equipped them with both hard and soft skills that have been useful for other health programs. A respondent from an international NGO reflected:
“I’ve had to work in a few other terrains like routine immunization, HIV and TB, you know and then this polio space, right. It’s interesting because it’s one place where I have seen a constellation of efforts from different stakeholders and players” (National Level Worker, Abuja)
“It is hard to work with the polio program but it makes your life easier because it gives you the capacities, it gives you the right understanding of knowing the things and it gives you the proactive approach. So, you will not be surprised by anything and you will not face any difficulties, you can overcome anything. So, it was a good experience” (National actor, Abuja)
Respondents who simultaneously engaged in the polio eradication program and other health programs reported that combining the PEI and other health programs contributed significantly to their workload. They noted that this was time-consuming, hectic, and adversely affected their personal lives. Additionally, combining these health programs often resulted in role conflict either among the health workers delivering the intervention or the donors supporting the various health programs.
Others stated that combining polio program activities with other health programs equipped them with the capacity to handle the challenges and buttressed the possibilities of elimination of other vaccine-preventable diseases in the country using capacities from the polio program. They also highlighted that integration of these health programs makes it possible to leverage the strengths of one health program for other programs. See Table 2 for a summary of the perceived benefits and challenges with illustrative quotes.
Similarities and distinctions between PEI, routine immunization, and other health programs
Comparisons between polio and other health programs
There were some observed similarities between the polio program and other health programs due to the coordination of all primary health care services including immunization by the NPHCDA. The NPHCDA is an agency tasked with supporting the promotion and implementation of high-quality and sustainable primary health care for all through resource mobilization, partnerships, collaboration, the development of community-based systems, and functional infrastructure.
Consequently, there has been a degree of integration of PEI and other health care activities. Interviewees also highlighted overlaps in the activities of the health workers who deliver health interventions through PEI and other programs.
“There is similarity because, it is the same structure, the same ward focal person, the same PHC department, the same structure at the PHC level, even at the state level, the same ward focal person at ward level, and the same health workers, and the same kind of village health workers that we get them to enter house-to-house to vaccinate the children. They are the same people that used then to distribute the net” (Sub-national Level, Nasarawa)
This was also described by another interviewee:
“They are the same health workers down the different levels of health delivery. It’s the same as doing CHIPS, that’s the Community Health Influencer Promoter and Services. I’m still going through some other work in Primary Health Care and public health generally. It is the same health workers, the vaccinators delivering the oral polio vaccines who will be deployed to distribute nets from house to house. The same ward focal point person who will be doing the polio supplemental activities...” (National level Worker, Abuja)
The similarities between PEI and other health programs are highlighted in Box 2 below.
Differences between polio and other health programs
Some distinctions were reported between activities in the polio program and other health programs. These differences arise from the sense of urgency associated with polio eradication activities in the country. For instance, there is increased community engagement, the collaboration between the partners and the government institutions to ensure that the poliovirus is eradicated. This is not as emphasized in other health programs. With this high level of collaboration comes substantial funding which has not been recorded in other programs. This sense of urgency in the polio program inadvertently resulted in an increase in workload for some polio staff, especially those engaged in other health programs. The attention given to the polio program unintentionally diverted much-needed resources from other routine health services.
“The sense of urgency for polio, that is different from the other programs, and the government is committing a lot of resources…” (National Level Worker, Abuja)
Furthermore, the participants remarked that because the PEI was better funded than other health programs, it got more attention than other routine health programs.
“The difference is because, in Nigeria, a lot of our health programs are heavily funded by donors, where there is donor funding there is more focus. So, if you talk about HIV/AIDS, prevention of mother to child transmission of HIV/AIDS, or in PMI program (Presidential Malaria Initiative) once there is funding, it gains a lot of attention, people are working hard on it, and that is how polio is but compared to other programs, maybe the Malaria is not as heavily funded as polio, I’m not sure, or maybe things like that are changing” (National level worker, Abuja)
“Polio program differs from them because of the support that it gets. In terms of political support, political commitment, and the funds that are provided to polio” (National level worker, Abuja)
Other interviewees further reflected that the polio program in the country was better planned, more comprehensive, and more data-driven when compared to other health programs within the country:
“There is no program to my knowledge that has that level of detail as the polio program. So, I’m talking of the general organization now, then, in terms of data, the data management in the polio immunization program is far, far more comprehensive. It differs in one basic way which is that polio program is more data-driven, it involves the community more, we have greater community participation, and you, you have more, corroboration between government and partners” (National level worker, Abuja)
Additionally, it was noted that both programs differed in the target population for the intervention, the level of commitment of partners involved in the program, and the level of awareness in both programs.
“Immunization only deals with children, but (other health programs) Malaria is not only for the children. It’s affecting both children and the adults” (National level worker, Nasarawa)
“I think one of the backbones of polio eradication initiative is the strong partners base, it’s the strong commitment of partners. Yes, then secondly, I think it’s the system; for polio eradication, there is a system in place and again for polio eradication, there is more awareness compared to others and more awareness, more sensitization, and more involvement of especially the traditional and religious leaders. And you know, right now you know, people are very much aware of the polio program unlike before. (National level worker, Nasarawa)
Box 3 below summarizes PEI’s advantage over other health programs.
Differences between PEI programs and routine immunization programs
The interviewees also observed differences in implementation strategies of both programs, more monetary motivation for health workers engaged in PEI programs, more political will for polio programs, and an additional health workforce channeled to the PEI because it is a global program with a sense of urgency.
“It is different. You know RI is based on the fixed post. But for the polio program, it is house-to-house.” (National level worker, Nasarawa)
“The challenge is because there is a lot of money in polio. People are paid, motivated at different levels, when you talk Polio, people jump up when you talk routine immunization, there is no money, so it’s like whatever, they are not as interested, and then there is some, political will for polio was higher in general compared to routine immunization. It had more visibility because it was presented at the Presidential Task Force, compared with routine immunization. Even all of that is changing, now, but initially, at least that’s what I observed when I came in (National level worker, Abuja)
“My answer will be yes and no because Polio is part of routine immunization. However, as you know, it’s different in the sense that Polio eradication is like an emergency., It is a global emergency so because of it there are additional human resources that are working at both the government and partner level to make sure that this eradication happens.” (National level worker, Abuja)
Positive contributions of the PEI to health programs within Nigeria’s health system
Regardless of the differences between the polio program and other health programs, interviewees noted that the polio program has positively contributed to the operations of other health programs. Respondents noted that resources, training, knowledge, experience, and innovations from the PEI are useful for other health programs and for strengthening the health system. The respondent remarked:
“The resources, as well as the equipment that are provided for the polio eradication program and the training that health care workers get from the polio eradication program, are very useful in their functioning in addressing other health-related problems” (National level, Abuja)
“And any subsequent program that will come up, the training, the knowledge, the experience and the innovations of the polio program will be quite useful in the other disease eradication or just to beef up the health systems so that other diseases can be better handled” (National Level, Abuja)
A frontline health worker provided more details on the use of health camps during polio programs to promote healthy behavior in the community: The health worker thinks that this strategy, where community members gather with the health workers in a designated location to be educated and vaccinated, may be adopted for other health programs.
“Yes, it has an impact on so many other aspects. Like malaria prevention, because we give mosquito nets. Apart from that, people are now conscious of so many health issues because in Kano state they use the strategy of health camps. Before the health camp strategy, the town announcer announces that people are coming to give immunization and other health advice. When the health workers reach such facilities people will gather where the health workers are camped and receive a lot of health talks not only on polio, so I think this is a good idea” (Frontline health worker, Kano)
Another interviewee spoke about the adoption of experiences in community mobilization and dialogue from the polio program in improving coverage in other health programs:
“So due to our experience from working with the polio program, we applied the same method in the maternal and child health week to get more coverage. We made announcements in the churches, and the mosques and had a community dialogue. (Frontline health worker, Nasarawa)
The participants also acknowledged that the lessons from the polio program have been applied to other health programs such as the routine immunization program, maternal and child health programs, and water and sanitation health programs. These lessons ranged from the utilization of existing polio physical structures (the emergency operation center), social structures (religious and traditional leaders), and technology (geographic information system). However, one of the most discussed impacts was the use of the EOC in the 2014 Ebola crisis which took place in Nigeria.
“So, remember it was a polio group that responded to the Ebola, because they already have a systematic way of responding to outbreaks, so they used that for the Ebola” (Sub National Level, Abuja)
“I remember the Ebola case in Lagos, it was the polio structure from Abuja that was moved to Lagos and that’s why you saw it didn’t spread. So, with all the expertise, when there is a case of polio there is a way we go about it. So immediately they relocated to Lagos everything was curtailed” (Sub National Actor, Nasarawa)
“We used it (polio structures) a lot for measles, so all those people that you see at the measles (campaign), they are learning straight up from here - how we do micro plans, going to the field, community engagement, and work a lot with traditional leaders” (National Level, Abuja)
In terms of skills, respondents identified aspects other programs could learn from the polio program. A respondent from a partner organization highlighted that the advocacy skills from the polio program have been useful for other health initiatives. He noted:
“In the course of our (polio) advocacy, we meet with different people. Let me give you an example: because I was part of the state technical committee, there was a time during the measles campaign, an issue now came to the State Task Officer that people were not willing to accept the measles vaccine. We stepped in to resolve the situation” (Sub National Level: Rotary, Oyo)
About structures, technologies such as the geographical information system (GIS), physical infrastructure such as the Emergency Operation Center, polio laboratories were identified to have contributed significantly to other programs and also have the potential to contribute even more. Interviewees from international partner agencies reflected:
“So, one of them is GIS or technology that has been used for measles campaign, yellow fever campaign, so you can use that to monitor where the workers go. That can be used for routine immunization outreaches” (National Level Worker, Abuja)
“We have the polio labs which can be transformed to do any other diseases, we can start testing for Ebola, we can start testing for Measles, Yellow Fever, Lassa fever.” (National Level Worker, Abuja)
“I hope that the Emergency Operations Centers’ scope of work will now be expanded for any emergency outbreak, health-related or development-related issue so that these systems will be there and will continue working and will help us to react quickly whenever there are outbreaks like Lassa and other diseases” (National Level Worker, Abuja)
In areas of social networks, the polio program has developed an extensive social structure from the community to the national level which engages the members of the community, religious leaders, and traditional leaders. This social structure was identified as very likely to be useful for other health programs. One interviewee from a partner organization noted:
“The other thing is the strength of the traditional system support, why can’t we leverage that for maternal and child health programs and other primary health care programs system? In fact, why can’t we layer that on top of it, to drive home uptake for it? And I’m sure this is already happening because we started seeing the impact of traditional systems well-coordinated within the polio program. I’m sure the other programs have started seeing just the need to layout support on all that” (National Level Worker, Abuja)
Figure 1 summarizes how PEI positively influenced other health programs as well as the health system, according to the respondents.
Negative unintended consequences of PEI on other health programs in Nigeria
Some respondents noted that the major adverse effect of the polio program on the health system is shifting the attention of the health workers from their primary roles and responsibilities to the polio campaigns. They mentioned the extra monetary incentives for participation during polio campaigns were the principal cause of the piqued interest in the PEI program when compared to other programs within the health system. Due to their participation in these frequent SIAs, they neglect other program service deliveries and acquired additional/increased workload. While a respondent noted that this is detrimental to the delivery of primary health services in rural communities with a limited number of health workers.
“…Services that have been positively or negatively affected by the polio eradication program; I think one obvious one is during supplemental immunization activities; the attention of health care workers tends to be more towards the supplemental immunization activities rather than routine immunization. And naturally, I mean, every human being, if you are going to get a little bit of more additional personal income, you will tend to be attracted to that.” (National level worker, Abuja)
“The changes that occur, is you will see, you find out that we are, that we are not just me but we are very inefficient in offering other services, like Polio Eradication initiative or Polio Eradication, campaign consume a lot of our time and so we do less in other service deliveries” (Sub-national actor, Nasarawa)
“Other interventions, for example, routine immunization, have suffered; why? Because, the polio program has an element of funding, employing ad hoc workers who are normally people that are working in the health facilities, but because of the benefits that they derive in that polio program, they abandon their primary role, you know, trying to grab something from the polio program, thereby abandoning their primary responsibility and that has affected the health system, for example, the routine immunization, and other health interventions” (National Level Worker, Kano)
“Of course, you can imagine in some rural areas where you have maybe one qualified health care worker in a health facility, that is a problem. Whatever you want to do, if you want to ensure every child gets routine immunization, it will only be that health worker. If a woman comes to deliver, it will be that woman. If it is supplemental immunization activity you want to, it is that woman that will go and do” (National actor, Kano)
Missed opportunities for other programs to leverage the polio program
The interviewees also highlighted missed opportunities to apply lessons from polio eradication to other health programs which share similarities with the polio program. These include the supervision of field activities in maternal, HIV, and malaria programs. A participant remarked:
“It is still coming back to, you’re tracking vaccines, so if someone also was supposed to deliver HIV commodities or family planning commodities, you could also track if these things get to the health facility. Geocoordinates of our cases; so we have a geo special mapped of all the AFP cases, if I asked this is the only disease in the country where you can tell on a map where all the Wild Polio cases are, all the suspected AFPs are. You won’t do the same thing for HIV, you won’t do the same for Malaria, you don’t do the same for any kind of disease but for polio, you cannot. So, if you are also able to geo-map all the other diseases then you will find out what are the enabling factors that are allowing for those cases to transmit and those diseases to be transmittable around those areas and the people be that were at risk as well” (National Level Worker, Abuja)