WEBVTT 00:00:00.000 --> 00:00:03.339 align:middle line:90% [MUSIC PLAYING] 00:00:03.339 --> 00:00:07.070 align:middle line:90% 00:00:07.070 --> 00:00:08.570 align:middle line:84% SVEA CLOSSER: So now that we've gone 00:00:08.570 --> 00:00:11.720 align:middle line:84% over the major actors in the Global Polio Eradication 00:00:11.720 --> 00:00:15.320 align:middle line:84% Initiative, we're going to turn our focus to some challenges. 00:00:15.320 --> 00:00:17.150 align:middle line:84% And there were a few major challenges 00:00:17.150 --> 00:00:19.670 align:middle line:84% due to the structure of the alliance that became clear 00:00:19.670 --> 00:00:22.380 align:middle line:90% in the early 2000s. 00:00:22.380 --> 00:00:25.490 align:middle line:84% So as you may remember, polio eradication 00:00:25.490 --> 00:00:28.100 align:middle line:84% was supposed to be achieved by the year 2000, 00:00:28.100 --> 00:00:29.900 align:middle line:90% but this didn't happen. 00:00:29.900 --> 00:00:32.810 align:middle line:84% In retrospect, this was probably never that realistic, 00:00:32.810 --> 00:00:35.540 align:middle line:84% since much of sub-Saharan Africa and South Asia 00:00:35.540 --> 00:00:39.680 align:middle line:84% did not even start vaccination campaigns until the late '90s. 00:00:39.680 --> 00:00:43.640 align:middle line:84% But this map shows that in much of sub-Saharan Africa and South 00:00:43.640 --> 00:00:47.790 align:middle line:84% Asia, there were still polio cases in the year 2000. 00:00:47.790 --> 00:00:51.600 align:middle line:84% Part of the challenge was that the partners, although they 00:00:51.600 --> 00:00:55.860 align:middle line:84% did have defined roles as we discussed in the last lecture, 00:00:55.860 --> 00:00:58.040 align:middle line:84% weren't always completely clear about who 00:00:58.040 --> 00:01:00.240 align:middle line:90% was supposed to be doing what. 00:01:00.240 --> 00:01:04.200 align:middle line:84% In 2003 and 2004, there was extensive conversation 00:01:04.200 --> 00:01:08.010 align:middle line:84% about this and, in addition, a letter clarifying roles. 00:01:08.010 --> 00:01:09.750 align:middle line:84% And a global-level policymaker said, 00:01:09.750 --> 00:01:12.900 align:middle line:84% quote, "This letter has given the immense impact 00:01:12.900 --> 00:01:15.150 align:middle line:84% at the ground level, and we have divided our role." 00:01:15.150 --> 00:01:15.720 align:middle line:90% End quote. 00:01:15.720 --> 00:01:18.150 align:middle line:90% And this was really helpful. 00:01:18.150 --> 00:01:20.400 align:middle line:84% While the role clarification helped, 00:01:20.400 --> 00:01:22.470 align:middle line:90% there were still issues. 00:01:22.470 --> 00:01:26.520 align:middle line:84% For example, the WHO, from the perspective of other partners, 00:01:26.520 --> 00:01:29.310 align:middle line:90% wanted control over the program. 00:01:29.310 --> 00:01:31.830 align:middle line:84% Whether or not that's true, there was certainly 00:01:31.830 --> 00:01:35.820 align:middle line:84% a degree of opacity within the WHO structure, 00:01:35.820 --> 00:01:38.905 align:middle line:84% and they had a command-control-mentality 00:01:38.905 --> 00:01:40.530 align:middle line:84% where they often told other people what 00:01:40.530 --> 00:01:42.420 align:middle line:90% was going to happen. 00:01:42.420 --> 00:01:43.860 align:middle line:84% This influenced how decisions were 00:01:43.860 --> 00:01:46.650 align:middle line:84% made both regionally and nationally 00:01:46.650 --> 00:01:48.480 align:middle line:84% and led to what some have described 00:01:48.480 --> 00:01:51.060 align:middle line:84% as organizational dysfunction within the Global Polio 00:01:51.060 --> 00:01:53.310 align:middle line:90% Eradication Initiative. 00:01:53.310 --> 00:01:55.590 align:middle line:84% The image here is from the Independent Monitoring 00:01:55.590 --> 00:01:58.510 align:middle line:84% Board for polio, which we'll talk about in a moment, 00:01:58.510 --> 00:02:01.590 align:middle line:84% but they're trying to encourage the partners to keep 00:02:01.590 --> 00:02:04.380 align:middle line:84% in their lane, more or less, that each 00:02:04.380 --> 00:02:06.630 align:middle line:84% of these organizations have something they're supposed 00:02:06.630 --> 00:02:10.110 align:middle line:84% to be doing, that they should specialize in it, focus on it, 00:02:10.110 --> 00:02:11.880 align:middle line:84% and build their expertise on that, 00:02:11.880 --> 00:02:15.590 align:middle line:84% rather than all of them trying to control everything. 00:02:15.590 --> 00:02:17.510 align:middle line:84% So there was a second set of challenges 00:02:17.510 --> 00:02:20.400 align:middle line:84% that became very clear in the early 2000s, 00:02:20.400 --> 00:02:22.400 align:middle line:84% and this is a set of challenges about what we're 00:02:22.400 --> 00:02:24.890 align:middle line:90% going to call parallelism. 00:02:24.890 --> 00:02:27.350 align:middle line:84% And this means that in places with the weakest health 00:02:27.350 --> 00:02:29.600 align:middle line:84% systems, health systems that were not set up 00:02:29.600 --> 00:02:33.800 align:middle line:84% to provide really maybe any services, or certainly not 00:02:33.800 --> 00:02:37.820 align:middle line:84% quality services, the Global Polio Eradication Initiative 00:02:37.820 --> 00:02:42.500 align:middle line:84% built their own system, staffed largely by WHO and UNICEF, 00:02:42.500 --> 00:02:45.230 align:middle line:84% to carry out key tasks like surveillance, 00:02:45.230 --> 00:02:48.140 align:middle line:84% and monitoring, and evaluation that governments did not 00:02:48.140 --> 00:02:50.300 align:middle line:90% have the capacity to do. 00:02:50.300 --> 00:02:53.270 align:middle line:84% This was a short-term gain strategy. 00:02:53.270 --> 00:02:55.760 align:middle line:84% They felt that it was too long term and too 00:02:55.760 --> 00:02:58.310 align:middle line:84% difficult to try to build health systems everywhere 00:02:58.310 --> 00:02:59.790 align:middle line:90% in the world. 00:02:59.790 --> 00:03:02.150 align:middle line:84% And so to try to eradicate polio, 00:03:02.150 --> 00:03:05.670 align:middle line:84% they built what they needed to do to get the job done. 00:03:05.670 --> 00:03:08.330 align:middle line:84% But this meant that weak health systems were bypassed 00:03:08.330 --> 00:03:10.280 align:middle line:90% rather than strengthened. 00:03:10.280 --> 00:03:13.250 align:middle line:84% It was a strategy that seemed effective in the short term, 00:03:13.250 --> 00:03:15.170 align:middle line:84% but it meant that government staff often 00:03:15.170 --> 00:03:19.290 align:middle line:84% felt that polio eradication was a WHO and UNICEF program, 00:03:19.290 --> 00:03:22.540 align:middle line:84% which, in fact, in practice, it often was. 00:03:22.540 --> 00:03:26.020 align:middle line:84% So in the year 2000, routine immunization coverage 00:03:26.020 --> 00:03:28.760 align:middle line:84% was low across much of the world. 00:03:28.760 --> 00:03:32.590 align:middle line:84% So in this chart, all of the lightest color blue countries 00:03:32.590 --> 00:03:37.232 align:middle line:84% had lower than 40% immunization coverage in the year 2000. 00:03:37.232 --> 00:03:39.190 align:middle line:84% So you can see that much of sub-Saharan Africa, 00:03:39.190 --> 00:03:42.280 align:middle line:84% fewer than 40% of kids were being fully immunized. 00:03:42.280 --> 00:03:47.200 align:middle line:84% This meant it was a huge lift to fill that gap with campaigns 00:03:47.200 --> 00:03:49.270 align:middle line:90% with polio vaccine. 00:03:49.270 --> 00:03:52.120 align:middle line:84% Yet the parallel structure of the polio program 00:03:52.120 --> 00:03:55.510 align:middle line:84% meant that these issues about poor routine immunization 00:03:55.510 --> 00:03:58.040 align:middle line:90% were not really being addressed. 00:03:58.040 --> 00:04:00.820 align:middle line:84% So by the mid-2000s, these organizational issues 00:04:00.820 --> 00:04:02.800 align:middle line:84% had led to repeated missed deadlines, 00:04:02.800 --> 00:04:05.620 align:middle line:84% which became a major problem for the program. 00:04:05.620 --> 00:04:09.010 align:middle line:84% Some major bilateral donors felt they had been misled 00:04:09.010 --> 00:04:11.440 align:middle line:84% and funding was beginning to dry up. 00:04:11.440 --> 00:04:15.220 align:middle line:84% This map shows how widespread polio was in 2007, 00:04:15.220 --> 00:04:17.529 align:middle line:84% including massive outbreaks in northern India 00:04:17.529 --> 00:04:19.120 align:middle line:90% and northern Nigeria. 00:04:19.120 --> 00:04:21.970 align:middle line:84% So as you can see, there's polio cases 00:04:21.970 --> 00:04:24.850 align:middle line:84% across much of sub-Saharan Africa, 00:04:24.850 --> 00:04:28.230 align:middle line:84% and pretty much Afghanistan, Pakistan, India 00:04:28.230 --> 00:04:30.220 align:middle line:90% are all polio endemic. 00:04:30.220 --> 00:04:32.410 align:middle line:84% So polio eradication leadership initially 00:04:32.410 --> 00:04:35.350 align:middle line:84% responded to these challenges by simply pushing back 00:04:35.350 --> 00:04:37.720 align:middle line:90% the goal end date year by year. 00:04:37.720 --> 00:04:39.760 align:middle line:84% So the goal of polio eradication was 00:04:39.760 --> 00:04:43.900 align:middle line:84% announced to be 2005, and then 2006, and then 2007, 00:04:43.900 --> 00:04:47.380 align:middle line:84% and then 2008, and none of those goals were met. 00:04:47.380 --> 00:04:50.860 align:middle line:84% So optimistic projections that were repeatedly not met 00:04:50.860 --> 00:04:53.260 align:middle line:90% made donors very nervous. 00:04:53.260 --> 00:04:56.410 align:middle line:84% And this points to the need to dynamically adapt 00:04:56.410 --> 00:04:58.510 align:middle line:84% goals based on analysis of reality 00:04:58.510 --> 00:05:00.723 align:middle line:84% and not what you wish would happen, 00:05:00.723 --> 00:05:02.140 align:middle line:84% something that many observers felt 00:05:02.140 --> 00:05:04.630 align:middle line:84% was not going on in the mid-2000s. 00:05:04.630 --> 00:05:06.460 align:middle line:84% Adding to this were the challenges 00:05:06.460 --> 00:05:09.490 align:middle line:84% in the global alliance we just discussed. 00:05:09.490 --> 00:05:12.780 align:middle line:84% So in the mid-2000s, the reticence 00:05:12.780 --> 00:05:14.880 align:middle line:84% of some traditional donors to keep 00:05:14.880 --> 00:05:17.520 align:middle line:84% giving to polio eradication paved the way 00:05:17.520 --> 00:05:20.880 align:middle line:84% for a new donor, the Gates Foundation. 00:05:20.880 --> 00:05:22.740 align:middle line:84% The Bill and Melinda Gates Foundation, 00:05:22.740 --> 00:05:24.840 align:middle line:84% like Rotary International before it, 00:05:24.840 --> 00:05:27.480 align:middle line:84% was seeking a champion cause, but they 00:05:27.480 --> 00:05:29.940 align:middle line:84% had a different ethos and different principles 00:05:29.940 --> 00:05:31.590 align:middle line:90% than other partners. 00:05:31.590 --> 00:05:33.720 align:middle line:84% And this further exacerbated some 00:05:33.720 --> 00:05:35.580 align:middle line:84% of the organizational tensions that 00:05:35.580 --> 00:05:38.430 align:middle line:90% had been ongoing previously. 00:05:38.430 --> 00:05:41.370 align:middle line:84% But this graph shows the money available for polio 00:05:41.370 --> 00:05:43.773 align:middle line:90% eradication year by year. 00:05:43.773 --> 00:05:45.690 align:middle line:84% As you can see, there wasn't much money at all 00:05:45.690 --> 00:05:49.890 align:middle line:84% given to the project until the very late '90s. 00:05:49.890 --> 00:05:54.180 align:middle line:84% In the early 2000s, donations increased a lot with the effort 00:05:54.180 --> 00:05:56.677 align:middle line:84% to try to finally get rid of polio. 00:05:56.677 --> 00:05:58.260 align:middle line:84% And then the yellow bars at the bottom 00:05:58.260 --> 00:06:02.460 align:middle line:84% of the image, which are mostly Gates Foundation money, led 00:06:02.460 --> 00:06:05.820 align:middle line:84% to an increase in the overall budget around 2010. 00:06:05.820 --> 00:06:08.190 align:middle line:84% However, this infusion of cash did not 00:06:08.190 --> 00:06:10.620 align:middle line:90% lead to a quick end of polio. 00:06:10.620 --> 00:06:14.460 align:middle line:84% Compare this budget, over $1 billion a year, 00:06:14.460 --> 00:06:17.010 align:middle line:84% with the optimistic projections about the cost of polio 00:06:17.010 --> 00:06:20.220 align:middle line:84% eradication in the early years and the very low levels 00:06:20.220 --> 00:06:22.470 align:middle line:84% of funding in the '90s, despite the fact 00:06:22.470 --> 00:06:24.720 align:middle line:84% that polio eradication was declared as a goal 00:06:24.720 --> 00:06:28.160 align:middle line:84% by the World Health Assembly back in 1988. 00:06:28.160 --> 00:06:32.660 align:middle line:84% So at this point around 2010, we have yet another actor, 00:06:32.660 --> 00:06:35.260 align:middle line:84% the Independent Monitoring Board. 00:06:35.260 --> 00:06:38.590 align:middle line:84% Throughout its 25-year history, the Global Polio Eradication 00:06:38.590 --> 00:06:40.690 align:middle line:84% Initiative has established and disbanded 00:06:40.690 --> 00:06:43.390 align:middle line:84% a number of boards, advisory groups, and committees 00:06:43.390 --> 00:06:46.480 align:middle line:84% to provide expertise and advice to the program. 00:06:46.480 --> 00:06:50.170 align:middle line:84% The Independent Monitoring Board is the first truly independent 00:06:50.170 --> 00:06:54.130 align:middle line:84% group charged with assessing the program's progress, strengths, 00:06:54.130 --> 00:06:57.520 align:middle line:84% and weaknesses, and it was created in response 00:06:57.520 --> 00:06:59.620 align:middle line:84% to a feeling by donors that perhaps they were not 00:06:59.620 --> 00:07:03.190 align:middle line:84% getting the full story or that perhaps an external board would 00:07:03.190 --> 00:07:04.790 align:middle line:90% be helpful. 00:07:04.790 --> 00:07:06.790 align:middle line:84% The Independent Monitoring Board was established 00:07:06.790 --> 00:07:10.030 align:middle line:84% at a critical time, after a difficult decade 00:07:10.030 --> 00:07:11.950 align:middle line:84% in which the incidence of polio remained 00:07:11.950 --> 00:07:15.130 align:middle line:84% more or less unchanged, despite considerable effort 00:07:15.130 --> 00:07:17.050 align:middle line:90% and investment. 00:07:17.050 --> 00:07:19.780 align:middle line:84% In 2010, the program resolved to break the deadlock 00:07:19.780 --> 00:07:22.210 align:middle line:84% and finally complete eradication. 00:07:22.210 --> 00:07:25.960 align:middle line:84% Establishing the IMB was part of its plan to do so. 00:07:25.960 --> 00:07:29.530 align:middle line:84% The concept of an IMB, or Independent Monitoring Board, 00:07:29.530 --> 00:07:33.070 align:middle line:84% is innovative, with no clear analog in the history 00:07:33.070 --> 00:07:36.760 align:middle line:84% either of polio eradication or in any other global health 00:07:36.760 --> 00:07:38.020 align:middle line:90% program. 00:07:38.020 --> 00:07:40.690 align:middle line:84% The IMB is a truly independent board 00:07:40.690 --> 00:07:45.070 align:middle line:84% established to evaluate and advise polio eradication. 00:07:45.070 --> 00:07:49.000 align:middle line:84% It holds meetings about once a year and releases a report. 00:07:49.000 --> 00:07:51.700 align:middle line:84% And these reports are, unlike most reports 00:07:51.700 --> 00:07:53.740 align:middle line:84% issued by global health organizations, 00:07:53.740 --> 00:07:56.380 align:middle line:84% truly interesting and revealing reading. 00:07:56.380 --> 00:07:59.530 align:middle line:84% They're full of provocative graphics and ideas. 00:07:59.530 --> 00:08:02.110 align:middle line:84% The IMB gives recommendations and attempts 00:08:02.110 --> 00:08:04.180 align:middle line:90% to ensure accountability. 00:08:04.180 --> 00:08:06.230 align:middle line:84% Ultimately, it has no real teeth, 00:08:06.230 --> 00:08:09.100 align:middle line:84% but it does have shaming power, and its recommendations 00:08:09.100 --> 00:08:11.790 align:middle line:90% are generally taken seriously. 00:08:11.790 --> 00:08:15.550 align:middle line:84% The IMB paved the way for major reforms in polio eradication 00:08:15.550 --> 00:08:17.630 align:middle line:90% after 2010. 00:08:17.630 --> 00:08:20.270 align:middle line:84% A global policymaker commented, quote, 00:08:20.270 --> 00:08:22.880 align:middle line:84% "There were just a few people in WHO who were 00:08:22.880 --> 00:08:24.890 align:middle line:90% making all of the decisions. 00:08:24.890 --> 00:08:27.380 align:middle line:84% And for many years, that command-and-control structure 00:08:27.380 --> 00:08:30.770 align:middle line:84% was very effective, worked very well, but then 00:08:30.770 --> 00:08:32.630 align:middle line:90% the program stalled. 00:08:32.630 --> 00:08:34.400 align:middle line:84% We had to do a full reorganization 00:08:34.400 --> 00:08:37.590 align:middle line:84% and reset so that there was a shared decision making. 00:08:37.590 --> 00:08:40.280 align:middle line:84% How do you superimpose that on an operational structure 00:08:40.280 --> 00:08:42.730 align:middle line:84% that was setup for command and control? 00:08:42.730 --> 00:08:45.380 align:middle line:84% And so that was very confusing for our field managers, 00:08:45.380 --> 00:08:47.708 align:middle line:84% for our regional managers, country managers. 00:08:47.708 --> 00:08:50.000 align:middle line:84% They felt that there were too many cooks in the kitchen 00:08:50.000 --> 00:08:51.600 align:middle line:90% making decisions." 00:08:51.600 --> 00:08:53.540 align:middle line:84% So while these changes were necessary, 00:08:53.540 --> 00:08:56.300 align:middle line:84% they were also not exactly straightforward. 00:08:56.300 --> 00:08:59.690 align:middle line:84% Today, the Global Polio Eradication Initiative 00:08:59.690 --> 00:09:02.210 align:middle line:84% operates on a decentralized, equal partnership 00:09:02.210 --> 00:09:04.520 align:middle line:84% model with shared decision making 00:09:04.520 --> 00:09:07.010 align:middle line:84% and delineated responsibilities drawing 00:09:07.010 --> 00:09:09.480 align:middle line:90% on each partners' strengths. 00:09:09.480 --> 00:09:12.520 align:middle line:84% A global policymaker said, quote, "After that, it 00:09:12.520 --> 00:09:15.490 align:middle line:84% was more of a true partnership established and sort 00:09:15.490 --> 00:09:17.260 align:middle line:84% of those management groups that, you know, 00:09:17.260 --> 00:09:20.290 align:middle line:84% provided a forum for discussions of the strategies and oversight 00:09:20.290 --> 00:09:22.000 align:middle line:90% of implementation. 00:09:22.000 --> 00:09:23.710 align:middle line:84% I think it was probably the realization 00:09:23.710 --> 00:09:26.170 align:middle line:84% that alone, WHO could not achieve it 00:09:26.170 --> 00:09:29.930 align:middle line:84% and needed true partnership to deliver on eradication. 00:09:29.930 --> 00:09:33.007 align:middle line:84% And the partners said, yes, we would want to be true partners, 00:09:33.007 --> 00:09:35.590 align:middle line:84% but then we would also need to be associated with the decision 00:09:35.590 --> 00:09:36.740 align:middle line:90% making. 00:09:36.740 --> 00:09:39.040 align:middle line:84% So it was redesigned in a way where all partners had 00:09:39.040 --> 00:09:41.350 align:middle line:84% a possibility of voicing their concerns 00:09:41.350 --> 00:09:44.590 align:middle line:84% and putting things on the table, so that one agency alone could 00:09:44.590 --> 00:09:46.100 align:middle line:90% not make all of the decisions." 00:09:46.100 --> 00:09:47.410 align:middle line:90% End quote. 00:09:47.410 --> 00:09:49.300 align:middle line:84% So of course, there are pros and cons 00:09:49.300 --> 00:09:52.490 align:middle line:84% of a centralized leadership versus more of a partnership, 00:09:52.490 --> 00:09:55.240 align:middle line:84% as no doubt you've experienced in your own work. 00:09:55.240 --> 00:09:58.390 align:middle line:84% But for polio eradication, it's widely 00:09:58.390 --> 00:10:01.420 align:middle line:84% agreed by our interviewees that it was a positive change 00:10:01.420 --> 00:10:04.390 align:middle line:84% to move to a more partnership model. 00:10:04.390 --> 00:10:06.790 align:middle line:84% Although the Global Polio Eradication Initiative 00:10:06.790 --> 00:10:09.460 align:middle line:84% had been a partnership on paper since the beginning, 00:10:09.460 --> 00:10:11.930 align:middle line:84% it hadn't always operated that way. 00:10:11.930 --> 00:10:13.870 align:middle line:84% A global policymaker said, quote, 00:10:13.870 --> 00:10:18.555 align:middle line:84% "For example, in Borno, Nigeria, in 2015 and 2016, 00:10:18.555 --> 00:10:19.930 align:middle line:84% we realized that the surveillance 00:10:19.930 --> 00:10:21.305 align:middle line:84% data that was coming out of Borno 00:10:21.305 --> 00:10:23.500 align:middle line:90% wasn't accurately geotagged. 00:10:23.500 --> 00:10:25.210 align:middle line:84% I'm going to be super candid, we all 00:10:25.210 --> 00:10:27.520 align:middle line:84% trusted WHO to report things effectively, 00:10:27.520 --> 00:10:29.610 align:middle line:84% and we realized it wasn't happening, 00:10:29.610 --> 00:10:31.690 align:middle line:84% and so that's an example of CDC in particular 00:10:31.690 --> 00:10:34.360 align:middle line:84% stepping in and saying, wait, what needs to happen here 00:10:34.360 --> 00:10:36.150 align:middle line:90% to make this work properly? 00:10:36.150 --> 00:10:37.900 align:middle line:84% So that's also kind of a check and balance 00:10:37.900 --> 00:10:40.233 align:middle line:84% thing, which I really appreciate about the partnership." 00:10:40.233 --> 00:10:40.880 align:middle line:90% End quote. 00:10:40.880 --> 00:10:43.570 align:middle line:84% And the point here is not that WHO, in general, 00:10:43.570 --> 00:10:44.890 align:middle line:90% wasn't doing a good job. 00:10:44.890 --> 00:10:47.890 align:middle line:84% They were doing amazing things in many places. 00:10:47.890 --> 00:10:49.780 align:middle line:84% But that allowing different partners 00:10:49.780 --> 00:10:52.780 align:middle line:84% to have more weight and more checks and balances 00:10:52.780 --> 00:10:56.380 align:middle line:84% was really positive for the program, in general. 00:10:56.380 --> 00:10:59.770 align:middle line:84% However, with the addition of more partners and more 00:10:59.770 --> 00:11:02.440 align:middle line:84% shared decision making, understanding 00:11:02.440 --> 00:11:05.230 align:middle line:84% the structure of the Global Polio Eradication Initiative 00:11:05.230 --> 00:11:09.020 align:middle line:84% and how decisions were made was really complicated. 00:11:09.020 --> 00:11:12.070 align:middle line:84% So this particular image is from the Independent Monitoring 00:11:12.070 --> 00:11:14.388 align:middle line:84% Board's eighth report, and I'm not even 00:11:14.388 --> 00:11:16.680 align:middle line:84% going to attempt to make my way all the way through it. 00:11:16.680 --> 00:11:19.480 align:middle line:84% But as you can see, there are a huge number 00:11:19.480 --> 00:11:23.140 align:middle line:84% of different agencies, partners, committees, 00:11:23.140 --> 00:11:27.080 align:middle line:84% all tasked with making various decisions in various ways. 00:11:27.080 --> 00:11:28.690 align:middle line:84% So the World Health Assembly, which 00:11:28.690 --> 00:11:31.180 align:middle line:84% is a meeting of governments, provides the highest level 00:11:31.180 --> 00:11:34.270 align:middle line:84% of governance for the GPEI, at least in theory. 00:11:34.270 --> 00:11:36.370 align:middle line:84% It issues resolutions that determine the scope 00:11:36.370 --> 00:11:38.530 align:middle line:84% and direction for the initiative, 00:11:38.530 --> 00:11:41.980 align:middle line:84% and it secures the commitment of the WHO member states. 00:11:41.980 --> 00:11:43.720 align:middle line:84% But the World Health Assembly meets only 00:11:43.720 --> 00:11:47.380 align:middle line:84% for a few days each year and has many agenda items. 00:11:47.380 --> 00:11:51.590 align:middle line:84% In practice, it tends to rubber stamp what WHO advises. 00:11:51.590 --> 00:11:53.340 align:middle line:84% So then the next level down in this chart 00:11:53.340 --> 00:11:58.260 align:middle line:84% we have the partners, WHO, Rotary, CDC, the Gates 00:11:58.260 --> 00:12:00.210 align:middle line:90% Foundation, and UNICEF. 00:12:00.210 --> 00:12:02.790 align:middle line:84% Then in addition, more layers below that, 00:12:02.790 --> 00:12:05.760 align:middle line:84% we have the Polio Oversight Board and the Polio Steering 00:12:05.760 --> 00:12:07.590 align:middle line:84% Committee, which have been created to bring 00:12:07.590 --> 00:12:09.600 align:middle line:90% all those partners together. 00:12:09.600 --> 00:12:11.970 align:middle line:84% And then a bunch of different advisory groups 00:12:11.970 --> 00:12:15.000 align:middle line:84% cutting across these, and this is even before governments 00:12:15.000 --> 00:12:16.700 align:middle line:90% get involved. 00:12:16.700 --> 00:12:20.270 align:middle line:84% So the cost of all of this organizational complexity 00:12:20.270 --> 00:12:23.960 align:middle line:84% is that good ideas often take a long time before they actually 00:12:23.960 --> 00:12:25.610 align:middle line:90% get implemented. 00:12:25.610 --> 00:12:28.970 align:middle line:84% A global level policymaker said, quote, "There's probably 00:12:28.970 --> 00:12:31.580 align:middle line:84% an opportunity cost associated with the partnership 00:12:31.580 --> 00:12:33.830 align:middle line:84% and the amount of conference calls, and meetings, 00:12:33.830 --> 00:12:36.500 align:middle line:84% and discussions, and partners that we need to have, 00:12:36.500 --> 00:12:39.980 align:middle line:84% which possibly sort of affects our ability to move faster. 00:12:39.980 --> 00:12:42.200 align:middle line:84% But I think that weighing the pros and cons, 00:12:42.200 --> 00:12:44.790 align:middle line:84% we still feel that this is the way it needs to work." 00:12:44.790 --> 00:12:46.200 align:middle line:90% End quote. 00:12:46.200 --> 00:12:48.480 align:middle line:84% So this image is from the Independent Monitoring 00:12:48.480 --> 00:12:51.060 align:middle line:90% Board in 2016. 00:12:51.060 --> 00:12:53.670 align:middle line:84% It shows that there was a gap of 29 months 00:12:53.670 --> 00:12:57.420 align:middle line:84% between the idea that combining oral and injectable polio 00:12:57.420 --> 00:13:00.120 align:middle line:84% vaccine would be a good thing and when that was actually 00:13:00.120 --> 00:13:03.270 align:middle line:84% done in a Kenyan refugee camp, and a gap of 18 00:13:03.270 --> 00:13:06.480 align:middle line:84% months between the idea that mandatory vaccination 00:13:06.480 --> 00:13:08.560 align:middle line:84% before travel would be a good idea 00:13:08.560 --> 00:13:11.730 align:middle line:84% and when the WHO actually recommended that. 00:13:11.730 --> 00:13:13.740 align:middle line:84% So this is, in many ways, a result 00:13:13.740 --> 00:13:15.780 align:middle line:84% of the bureaucracy of implementing 00:13:15.780 --> 00:13:17.430 align:middle line:90% these recommendations. 00:13:17.430 --> 00:13:20.780 align:middle line:90% [MUSIC PLAYING] 00:13:20.780 --> 00:13:25.000 align:middle line:90%