MIOLE, Giselle Lugo

4019R362-9
Human Development & SDGs (E)
Prof. KATSUMA Yasushi

Title: Ensuring Polio Eradication in Outbreak Countries

Subtitle: State and non-state actors’ responses to the polio outbreak in the Philippines
Abstract:
The global prevalence of polio led to various responses of the state actors and the rising
partnership roles of non-state actors. Immunization drives, surveillance programs and creative
campaigning are among the proposed solutions of state actors in the country. The case of the
reemergence of polio outbreak in the Philippines is worth taking to analyze by looking into the recurring
roles of state actors, such as Department of Health (DOH) and local government units (LGUs), and
identifying the potential roles of non-state actors, particularly NGOs. Using a literature review of
previous studies, policies, news articles focusing on the matter, the study aims to assess the responses
of major stakeholders and identify their gaps and challenges. Engagement of both state and non-state
actors and highlighting community participation programs have been suggested to play a vital role in
preventing polio in the country.
Keywords: Global Polio Eradication Initiative (GPEI), vaccine-derived poliovirus (VDPV),
Sustainable Development Goals (SDGs), outbreak, community participation

Introduction
Poliomyelitis (polio) is an infectious disease caused by the poliovirus that spreads through
orofecal transmission. It affects children ages 0-5 years old, invades their nervous system and causes
mild to deadly paralysis (CDC, n.d.; WHO, n.d.). Its global prevalence during the early 20th century led
to a consensus of developing IPV (inactivated poliovirus vaccines) and OPV (oral poliovirus vaccines)
(Paul, 1971, cited in Trevelyan, et al., 2004). Major stakeholders, such as WHO, national and local
government units (LGUs) alongside partnerships with NGOs implemented various responses to the
disease. In 1974, WHO established Expanded Program on Immunization (EPI) to immunize every child
from six vaccine-preventable diseases, including polio. EPI was also adopted by countries to implement
routine immunization programs nationwide. The following decade witnessed the launching of Global
Polio Eradication Initiative (GPEI), deemed as ‘the largest public health initiative in history’ by WHO
(Koenig-Archibugi, 2011), with the sole objective to eradicate wild poliovirus (WPV) by 2000, but the
goal was not achieved in the given time. Nevertheless, GPEI continues developing Polio Endgame
Strategy was established with four key strategies: surveillance; routine immunization; supplementary
immunization; and targeted mop-up campaigns (GPEI, n.d.).
Despite large-scale efforts, however, ensuring a world free of polio remains a challenge in the
global public health. This challenge is almost exclusive to developing countries in which WPV
continues to circulate. Low vaccination coverage, vaccine failure, poor hygiene and sanitation are
among the reasons why WPV transmission continues (Wassilak & Oresntein, 2014; WHO, 2017).
Consequently, a recent challenge emerged: the rise of vaccine-derived poliovirus (VDPV). The
mutation occurred when the weakened virus is excreted in an environment with inadequate sanitation
and poor hygiene, thereby facilitating its spread to nearby communities (WHO, 2017). Initially, public
health interventions were upon the responsibility of state actors, but the rise of contemporary non-state
actors were found to emerge through time (Held, 2015). These non-state actors include philanthropists,
private sector and NGOs that remain partners with state actors in a combined effort to eradicate polio.
This research paper aims to analyze the responses and challenges of state and non-state actors to the
polio outbreak in the Philippines.
 The Philippines was declared polio-free in 2000 as the last known WPV case was found in 1993.
However, in September 2019, a VDPV case was found in a 3-year-old girl in the Mindanao region,
leading to the declaration of the comeback of polio outbreak after 19 years (WHO, 2019). Interestingly,
these viruses were already detected positive from sewage samples in Manila and Davao regions (DOH,
2019)—a month before the reemergence of the outbreak. The country is also recovering from the
nationwide vaccine scare due to the controversial dengue vaccine called Dengvaxia in 2017 that derailed
the public and gained huge mistrust in vaccines in general (Lasco & Larson et al., 2019; Larson et al.,
2019). Despite these issues, responses are ongoing through domestic immunization efforts from the
Department of Health (DOH), and partnerships with international and local organizations. The
Philippines’ case is worth analyzing to look into how the government responds to the polio outbreak,
including the role of non-state actors in the course of eliminating polio in the country despite the
mentioned pressing health issues. The role of non-state actors, most especially NGOs is understudied
in the subject matter of polio eradication in the Philippines. In line with achieving Sustainable
Development Goals (SDGs) Goals 3 (good health and well-being) and 6 (clean water and sanitation),
this study aims to assess how state actors mainstream polio awareness and prevention in the country,
and the gaps and challenges that need to be addressed. The study also emphasizes the engagement of
non-state actors, particularly community mobilization programs of NGOs in playing a vital role in the
course of eliminating the disease.

Body
The Philippines has long been detected high-risk for poliovirus transmission (DOH, 2019) and
recognized as under-immunized due to the steady decline of compliance to the 95% minimum vaccine
coverage as mandated by WHO (DOH, n.d.; UNICEF 2019, cited in Thorton, 2019) (fig. 1). Upon the
Dengvaxia controversy, which led to the vaccine hesitancy among Filipinos in 2017, the vaccination
confidence spiraled down from 93% in 2015 to 32% in 2018 (Larson, et al., 2019). Towards the
reemergence of polio outbreak in 2019, DOH responded through implementing polio immunization
campaigns. However, due to understaffing of personnel and resources to reach every village, the
national government and LGUs seek support with non-state actors such as WHO, UNICEF, and Rotary
International. This discussion evaluates current responses of actors to polio outbreak in the Philippines.

Fig. 1 (Source: DOH)

State Actors’ Response
The spearhead actor DOH implements nationwide immunization programs, and coordinates
with LGUs across the country to facilitate house-to-house vaccine deliveries in the communities. It also
conducts surveillance programs throughout the major cities, and geographically isolated and
disadvantaged areas (GIDA) in the country. LGUs also play an important role in support of DOH’s
mandate of immunization programs. This section explores major responses of state actors DOH and
LGUs to polio in the country.
A. Routine immunization programs
DOH abides with EPI with the aim to vaccinate children and strengthen protection from the
following six vaccine-preventable diseases: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis
and measles (DOH, n.d.). Through Republic Act No. 10152 or the Mandatory Infants and Children
Health Immunization, the Philippine government (2011) mandates basic immunization services for
infants and children. The coverage has extended from six to nine determined vaccine-preventable
diseases, adding mumps, hepatitis-B and H. influeza type B (HIB) in the list. Other types of diseases
determined by DOH are also included. The mandatory immunization is given for free at health centers,
and public hospitals to children of 0-5 years old. Participants are entitled with Child Immunization
Record (fig. 2) given by DOH to keep track of their children’s vaccination coverages. “Todo Ligtas”
(Super Safe) and “’Pag Kumpleto, Protektado” (Once completed, your child is protected) are the
circulating slogans in posters, advertisements and immunization cards as a way of encouraging parents
to have their children vaccinated. Other policies included in this act are education and information
campaign; health personnel training and education; and obligation to inform parents or legal guardians
about the nature and benefits of immunization against the determined diseases.

Fig. 2 Child Immunization Record card (Source: DOH)

B. Sabayang Patak Kontra Polio (Synchronized Drop Against Polio)

Sabayang Patak Kontra Polio (SPKP) is a special nationwide immunization drive serving as
the primary response to the newly found circulating VDPVs and the reemerged polio outbreak in the
country. It aims to vaccinate children 0-5 years old regardless of their immunization status (RITM,
2019). The immunization is done through giving three doses of OPV for free at public and private
hospitals, as well as in barangay (village) centers. In the following month, apart from house-to-house
visits, DOH established Polio Patak (drop) Corners in hospitals and barangays and organized
scheduled immunization rounds. Essentially, SPKP’s polio vaccination drives are mostly administered
through barangay health workers (BHWs), and among healthcare professionals (i.e. doctors, nurses)
especially in reaching high-risk communities like slums and mountainous areas. The first few rounds
piloted in major cities in the country including National Capital Region (NCR) and high-risk areas such
as Lanao del Sur, Marawi, Davao City and Davao del Sur. Most of the rounds repeat the vaccine
coverages in these mentioned areas. The campaign is also currently backed by public and humanitarian
organizations such as the Research Institute for Tropical Medicine (RITM) and Philippine Red Cross
(PRC), as well as private health institutions such as St. Luke’s Medical Center.
The pilot rounds of SPKP campaign were deemed successful as DOH reported 96%
vaccination coverage of children 0-59 months old living in NCR and certain areas in Mindanao (DOH,
2019 12). In January 2020, however, polio cases in the country hit 16 when a polio case reached NCR,
as well as in more remote areas of Mindanao such as Basilan (WHO, 2020). As a response, DOH
continues facilitating and extending further rounds of immunization drives with continued coordination
with LGUs to the ongoing campaign.
C. Acute flaccid paralysis (AFP) surveillance program
Poor sanitation is one of the main issues pointed out by WHO (2019) that facilitated poliovirus
transmission. Given this condition, acute flaccid paralysis (AFP) surveillance and zero open defecation
(ZOD) programs are implemented and included as a response to polio in the country. It was found that
AFP is associated with circulating VDPV in 2001 (CDC, 2001), hence surveillance programs were
implemented. Surveillance programs in general are conducted to detect any imported virus and thereby
enable corresponding emergency response. And in the light of the recent polio outbreak, DOH urged to
continue and strengthen AFP surveillance programs to ensure the interruption of the poliovirus from
spreading. And as poliovirus is known to be transmitted orofecally (WHO, n.d.), AFP surveillance
programs are tied with ZOD program with the aim to lessen further cases of diseases caused by open
defecation and lack of toilets in households.
LGUs employ BHWs who act as frontlines in surveillance programs especially in the field of
detecting diseases and control in the country (DOH, 2014). They not only aide healthcare professionals
in surveying but also aide in promoting awareness in proper sanitation and hygiene by using posters
and visual aide posted in barangay health centers. Based on DOH’s Manual of Procedures for the
Philippine Integrated Disease Surveillance and Response (2014), BHWs who are committed in
reporting cases of notifiable diseases are called disease reporting advocates (DRA) (p. 21). However,
DRAs are usually deemed ‘overloaded and unmotivated’ due to the tedious requirements and
inefficiencies found in the flow of data collection and reporting (p. 4).
D. ‘Creative’ campaigns
Apart from immunization and surveillance programs, campaigning is one of the vital
approaches made with the main objectives of promoting awareness on diseases and encouraging parents
and legal guardians to have their children vaccinated. DOH has several platforms used in promoting
awareness. One of which includes the use of music, dance and audio-visual multimedia such as jingles,
advertisements and music videos broadcasted in televisions and social media nationwide. In 2017, in
line with World Immunization Week, a music video entitled “Baby Come BAK” was released targeting
parents and guardians to have their children vaccinated. This also raises importance of immunization
across ages. In this music video,
In the LGU level, during the recent polio outbreak, a case in Pasig City, NCR tapped a popular
noontime show ‘Eat Bulaga’ to campaign about polio vaccination. Eat Bulaga’s “Juan for All, All for
Juan” segment visited a barangay in the city, where hosts and comedians in the show flashed SPKP
posters and announced to all families to bring their children to on-site vaccination stations in the
community (Casinas, 2019). Another campaigning approach in the same city was to award free grocery
packages to first 100 families whose children were vaccinated with polio vaccine (Casinas, 2019). This
was done to persuade parents and guardians to have their children vaccinated in the light of the recent
outbreak.
E. Vaccination for travelers
In 2015, when WHO declared polio type 2 eradicated worldwide, it was proceeded by the
switch of trivalent (a type of vaccine that contains protection from all 3 types of wild poliovirus) to
bivalent OPV (a type of vaccine that protects from wild poliovirus type 1 and 3) (WHO, 2015). This
switch was done in order to achieve cost-effectiveness of polio vaccination worldwide. However, the
International Health Regulations (IHR) declared the Philippines as state infected with VDPV type 2
with risks of international spread (GPEI, 2019). Thus, WHO gave the Philippines a special clearance to
use the phased out trivalent OPV. The special clearance in the Philippines led to an international concern.
For instance, the late ASEAN Games 2019 hosted by the Philippines advised the ASEAN member
states’ visitors and athletes to be vaccinated by the trivalent OPV due to the circulating VDPV affecting
the host country (Ishak, 2019). Travelers coming to the Philippines are advised to be vaccinated with
the necessary vaccines to be protected from the mutated poliovirus.

Non-state Actors’ Response

Non-state actors have various responses including funding, technical assistance, etc. But during
immunization drives like in the Philippines, they are, at most, partners with state actors in dealing with
health issues. For instance, NGOs are employed in cases where lack of personnel to administer polio
vaccination emerged; volunteers from NGOs such as Rotary International are the ones who fill in the
personnel gap. Philanthropists and private sector such as Bill and Melinda Gates Foundation are the
actors who fund programs; NGOs like Rotary initiate policies such as community mobilization to
campaign about polio awareness, and good hygiene and sanitation. While they have the potential to
heighten awareness, however, the challenge still lies on the coordination with LGUs, given the devolved
health system. This section briefly focuses on non-state actors’ response to the polio issue through
narrating a case study on Rotary, an NGO in the Philippines.
Case: Rotary Philippines District in Quezon City, NCR
Rotary International is an NGO known to be one of the founding partners of GPEI, and the
NGO that aims to eradicate polio worldwide. Their well-known branding campaign is End Polio Now,
self-described as “the longest standing and most significant efforts” (Rotary, n.d.). In the national level,
Rotary employs community mobilization, and has come up with a clubbing system, divided into districts.
Each district has a group of community volunteers which the locals have built rapport with. Commonly,
one city has clusters of districts, but as for the case in the Quezon City, the whole city itself is one
district. (N. Cayaga, personal communication, January 31, 2020). Amidst the polio immunization
campaign spearheaded by DOH, the community volunteers take part in administering polio vaccination,
along with BHWs through house-to-house vaccinations, even reaching the slum areas of the community.
The advantage of Rotary community volunteers is the rapport they built with the people, which
eases communication and smooth-sailing process of educating the participants about polio, sanitation
and hygiene altogether. Although the community is still recovering from the vaccine scare issue, the
communication between the volunteers and the participants went smoothly because of the rapport.
Another advantage of the district is the well-coordination of LGU officials because some of the LGU
officials themselves are volunteering for the mobilization and they are also well-known in the
community. Aside from polio vaccination, community volunteers also campaign for sanitation and
hygiene and encourage people to use toilets and water faucets that the Rotary donated. The funding of
the programs came from the funding arm of Rotary, the Rotary Foundation, alongside Gates Foundation.
 However, challenges were recognized in the course of the community-based programs. One of
the challenges mentioned was the water crisis that happened in 2019, when water was not fully
accessible and the communities, along with the Rotary community volunteers, had to resort to comply
with the water rotational schedules imposed by the concessionaire. Another challenge is the
accessibility to slum areas, given the geographical situation and the occurrences of ‘no-show’ of
participants are still evident during house-to-house visits. To compensate to such gap, Rotarians assist
BHWs in manning the health centers, to make sure it is accessible to the people in the slums to be
vaccinated. Being a community volunteer is said to be a ‘thankless job’, given that there are no
incentives nor benefits entitled for the volunteers. (N. Cayaga, personal communication, January 31,
2020).

Gaps and Challenges

Vertical approach of polio campaigns
Focusing on the international level, GPEI itself has been a subject of criticisms, given that it
focuses on one health problem, often time-limited and managed internationally with large amounts of
funding and attention devoted to polio only (Koenig-Archibugi, 2011, p. 172, 174). However, WHO
brought the positive benefits of GPEI and other polio campaigns that cater other dimensions of health
systems. They stressed that the maintenance of laboratory networks created to support polio eradication
have also supported responses to other infectious diseases such as diphtheria, meningitis, rubella,
dengue and yellow fever (WHO, 2002, cited in Koenig-Archibugi, 2011).
However, the case in the Philippines may have a different context. As a developing country
with issues on environment, culture and society such as climate change; vaccine scare; war; conflict;
poverty issues; lack of medical infrastructure and personnel, among others, the stakeholders, especially
the state actors, continue to overlook at these dimensions interlinked in health systems. Relying mostly
on polio campaigning alone like SPKP is already a one-time, vertically intervened approach. As
scholars put it, such approach “distorts global health agenda that led to the neglect in health systems”
(Travis et al., 2005, cited in Harman, 2015). In addition, the impact of limited budget in the health sector
also adds difficulty in achieving high vaccine coverages especially in GIDAs where people have inequal
access to primary health care.
Lastly, another reason why vertical approach remains a gap and a challenge at the same time is
reflected in the lack of understanding on poor sanitation and hygiene campaigns. ZOD program has a
narrow understanding on sanitation issues in areas where water and toilets are inaccessible, thereby
compelling people in vulnerable situations resort to open defecation practices. A deep understanding in
culture and socio-economic status must be enforced in such policies. A study by Robinson and Gnilo
(2016) conducted in typhoon-affected areas in Central Visayas, Philippines suggested that community-
led sanitation programs are effective in promoting open defecation free communities and highlighted
the need for institutionalizing sanitation. Community-led programs also led to improved handwashing,
solid and liquid waste management and safe water use.
Devolution of health services
Another gap on the responses made is the apparent decentralized administration of power in
dealing with health issues like polio and other diseases. In essence, DOH delegates the tasks to LGUs
to administer the immunization and be the campaigner to promote awareness. This reflects the
devolution of healthcare systems where decentralization persists to small political units (Grundy et al.,
2003; Dayrit, et al., 2018). This leads to the actual issue: the commitment and political will of LGUs.
At the end of every intervention, it is still up to the decision of LGU officials to strategize and perform
the interventions. While it is said that having a decentralized health system enhances efficiency and
effectiveness of health services, however, this is not in the case of a country with cases of
underfinancing and recurring health budget cuts in the health sector. Such constrains can complicate
efforts and lose cohesion of hierarchy of health services (Grundy, et al., 2003, p. 9). Indeed, this is
reflected in the issue of vaccination in cases where communities are hard to reach given the social,
cultural and geographical situation, and the lack of personnel and financial resources allotted in this
matter. In cases of lack of manpower, the burden is substantially passed on to NGOs’ community
volunteers to fill in the gaps that the government should pay more attention to.
Lack of emphasis on community participation
Lastly, the overarching challenge in polio eradication is ensuring effective communication to
the communities. For instance, the strategy of LGUs of persuading the people through awarding them
limited free grocery packages is interesting to note, but its sustainability will be found fragile in the
long run, because it loses the purpose of the campaign: for the people to be engaged in knowing the
issue behind why children should be vaccinated. Additionally, participants will become too dependent
of the free giveaways, rather than instilling the true message of immunization.
As a possible solution, scholars suggested of strengthening the primary health care through
community participation (Burgess et al., 2017; Sanders et al., 2019) which the government has
overlooked. Scholars have found that engaging community participation is effective in terms of
increasing vaccine coverage, in the case of Pakistan’s polio eradication efforts (Habib et al., 2017).
Another case study in Nigeria has also found that volunteer community mobilizers has been
contributory in reducing rejections to polio immunization (Duru, et al., 2019). Although DOH and
LGUs employ BHWs to perform house-to-house vaccination, however, these BHWs are given inequal
incentives and benefits (Rodriguez, 2014). The government must reprogram community-based
programs like BHWs, given their inequal incentives and benefits received. They should also know the
importance of community health workers that act as key purveyors of important health messages who
are able to translate and effectively communicate with the communities that they had built rapport with.

Conclusion
Emphasis on immunization drives, along with surveillance programs and other forms of
creative campaigning such as the use of mass media and rewarding of goods are among the major
responses of state actors to the polio outbreak in the Philippines. However, overlooking cultural factors
of communities, along with lack of strengthening in BHWs policies and neglecting underlying issues
like vaccine hesitancy are among the gaps and challenges in which can add constraints in ensuring polio
eradication in the country. While the health system intervention is LGU-based, community participation
must be engaged through empowering BHWs and non-state community volunteers in order to deliver
key messages to the people who need information about polio. The state actors place a steppingstone
of heightening awareness to polio nationwide, while the non-state actors with community-led responses
play a vital role in improving vaccination coverage, as well as in bringing important messages and
campaigning to the people in the community.
Limitations
This study only focused on the Philippine government’s responses to the reemerged polio
outbreak starting in 2019, with a limited overview and literature review of the current policies involved.
This is also the same with non-state actors’ response, with only focusing on one case study on the
contributions of the NGO Rotary. A more descriptive analysis on community participation cases in the
Philippines is recommended for possible further studies.
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