Report of the Workgroup on Disease Elimination/Eradication and Sustainable Health Development

D. Salisbury*

Eradication initiatives have been both applauded for their successes (smallpox, poliomyelitis) and criticized for their failings (malaria, smallpox). The Workgroup on Disease Elimination/Eradication and Sustainable Health Development tried to identify the critical components of policy development, human resource utilization, financing and sustainability that contribute to prospects for success. Subgroups worked on each of the topics against a set of core questions (see Table 1).

Disease eradication is distinct from disease control. Terms such as "elimination" or "elimination as a public health problem" are often confusing and are best understood as subcategories of disease control. Their use should be avoided as far as possible, which leaves only eradication initiatives and ongoing disease control programmes as alternatives.

Because eradication programmes differ, it is difficult to generalize about them. Some diseases for eradication are of global importance, while others may be of regional or local importance. How much emphasis is accorded to health system strengthening as an objective of eradication may vary depending on this fact and other features described by other work groups.

Eradication programmes cannot correct the deficiencies of existing health systems. Their objectives should be: 1) reduction of the target disease to zero incidence, and maintaining this when all interventions have ceased; and 2) strengthening and further development of health systems so that other disease control programmes and health system functions (e.g. monitoring and surveillance, supervision, and programme management) will also benefit from the eradication effort.

The group agreed that eradication programmes, besides reducing the incidence of a target disease to zero even after the discontinuation of control measures, have the potential to contribute greatly to the strengthening of health systems. These potential benefits should be identified and delineated at the start of any eradication initiative. As must be done for the disease eradication objective, measurable targets for achieving these development benefits should be set and the programme should be held accountable for their realization.

• Eradication initiatives should be implemented with the support of a broad coalition of partners. Great efforts should be made to build consensus and a shared sense of mission among United Nations agencies, the donor community (both public and private sector), and participating countries.
• Managers of eradication initiatives should respect the importance of other, ongoing public health programmes being promoted and implemented by the ministry of health and by other staff, internationally, nationally, and locally.
• To the extent possible, peripheral level decision-makers should be allowed to reach centrally established targets in a flexible and locally appropriate way. Similarly, when centrally driven priorities are set, those with responsibility at the peripheral level, who may have considerable autonomy for resource allocation, should understand their role within the wider objective.
• Successful eradication programmes are good examples of effective management. The programme activities should further the development of leadership and managerial skills among health personnel, building programme management capacities which the staff involved can carry to other health programmes.
• Surveillance of programmatic processes and outcomes (reduced morbidity and mortality) is important for successful eradication. The initiatives must demonstrate the principles of effective surveillance and actively develop and implement surveillance systems which can readily be adapted to meet the needs of other national priority programmes after eradication is achieved.

An eradication programme has the potential to produce substantial benefits to a health system beyond its disease-specific goals, but the following tensions are inherent to any consideration of whether to undertake an eradication initiative.

• Since other programmes will inevitably be sacrificed or delayed when an eradication goal is pursued, these opportunity costs should carefully be analysed prior to embarking upon an eradication initiative.
• The desire to show initial successes by starting an eradication initiative in the better prepared countries is balanced by the fact that less developed countries need more time to realize fully the potential benefits of eradication. Yet frequently, as is the case with poliomyelitis eradication, the countries which need the most time to develop sustainable surveillance systems, to raise vaccination coverage levels through routine vaccination programmes, and to strengthen programme management are paradoxically those which are accorded the least amount of time in which to attain disease eradication goals. Strategies, including flexibility in timing the introduction of interventions in order to achieve reductions in disease incidence and to strengthen the health system, should be developed to ensure that all countries benefit from participation in the programme.
• A balance must be achieved between two contrasting positions. First, some persons advocate eradication only when two outcomes can be assured, namely the absence of disease and the attainment of specific health service gains identified in advance of commencement of the eradication effort. Second, there is the view of the primacy of the eradication goal with a subsidiary objective of expected health service gains, which cannot be measured before the intervention commences. This exemplifies the tensions inherent in considering eradication targets.

Planners must assess the capacity of the current system to meet the requirements of the eradication intervention and identify opportunities for capacity building. Within existing systems, different levels of capacity exist in various countries. Planners need to assess objectively the operational levels of the system relative to the eradication objectives. This will include personnel available, cold chain integrity (if required), costs of delivery, transport requirements, other logistic needs, seasonal variations in epidemiology and transmission, anticipated opportunity costs, and social factors which may facilitate or impede achievement of the programme's objectives.

Once the assessment is complete, decision-makers must weigh the pros and cons of the eradication platform and decide whether to proceed or invest in pre-eradication interventions which will strengthen the system and enable a more effective and efficient eradication effort.

A time frame must be developed to sequence rationally the events towards eradication, and to improve the standards of delivery (e.g. logistics and supply, high quality service delivery, injection safety) and maximize the use of appropriate technologies. Planners must consider the sequence of events to implement the eradication programme relative to the operational requirements of the intervention. Cofactors within the eradication's operational structure should also be emphasized and applied within the existing health system to improve delivery standards. Appropriate technologies (e.g. VVMs, single-use syringes, drug inventory systems) should be considered and highlighted, as appropriate, to maximize delivery and improve the efficiency of eradication efforts and routine services.

Planning and design must maximize the partnerships of all potential stakeholders including the community, schoolchildren, local government, NGOs, and the private sector. Partnership is the key to effective eradication and control programmes. For the eradication programme, planners, decision-makers and donors must identify suitable partnerships among private and public sector colleagues. The essence of workable partnerships must include a common, long-term commitment to the eradication platform, clear lines of responsibility among partners (based on respective comparative advantages), and, on-the-ground planning of interventions.

Clear agreement on impact indicators, benchmarks of progress, key results, and the performance of each partner will favour smooth implementation and enable discrete and empirical assessments of each partner's input and output. Working together to achieve a common goal is a strong advantage of eradication programmes; coupled to system strengthening, this becomes a powerful combination to achieve sustainable success within a reasonable time frame. Clear examples should be drawn from the poliomyelitis eradication experience to enunciate the nature of workable partnerships and an empirical appraisal of sustainable, system-strengthening impact.

For eradication, the quality of delivery (safety, coverage, effectiveness and efficiency) must be ensured. Quality assurance is a key aspect of eradication and control programmes. The eradication effort must first assess the quality, stability, financing and efficiency of national programmes, and identify any weak points.

If safety issues arise, either from injections or drug distribution, planners and donors must proceed with caution or postpone embarking on the eradication effort until a reasonable level of confidence is displayed by all partners. Efforts must not be jeopardized by uncertainties related to quality, delivery, assessment and/or impact. Embarking prematurely, without proper consideration of quality, safety, effectiveness and efficiency, can result in extended efforts with higher costs, less system strengthening, and poor planning and judgement. Positive lessons from the poliomyelitis eradication initiative should be identified and applied to ensure future quality, safety, effectiveness and efficiency.

Eradication requires the development of monitoring systems that use quantitative and qualitative indicators to identify gaps between standards and performance. These data must be used to improve and sustain the quality of delivery systems in a continuing process. Monitoring systems must be put in place to track the approved indicators of both performance and impact. Without quantitative indicators that focus on quality, the benefits of the eradication effort will be compromised. Although eradication need not solve the problems of health systems, it must ensure the quality of delivery, and impart a lasting impact in terms of human, logistic, administrative, and technical processes. From the initial planning phases, empirical benchmarks of quality must be derived and monitored.

Any eradication programme must include "surveillance for action" both for the eradication and for the development of the surveillance infrastructure, which includes all stakeholders (i.e. public and private). For example, detection of a case of acute flaccid paralysis needs to include a response at each level of the system -- that is, parental instructions at the household level, investigation, laboratory collection, reporting at the district level, and appropriate mop-up. "Surveillance for action" thus encompasses system strengthening, information flow, and response. The positive development and impact of a grass-roots surveillance system is clear. Every effort should be made among partners to establish a sensitive and specific surveillance system that responds to unusual events.

Investments that promote sustainability through self-reliance, must be pursued in contrast to top-down, donor-driven efforts that impart little lasting impact. Lessons must be gleaned from the Latin American experience to ensure that appropriately strengthened surveillance systems are put in place which can serve routine systems elsewhere and future eradication efforts in general. Every effort should be made to document the success and shortcomings of the poliomyelitis eradication initiative regarding surveillance and certification.

Eradication must support applied research in the field to identify strategies, and track the effectiveness and efficiency of delivery of the interventions. Applied and operations research must be conducted to improve the effectiveness of administrative and technical interventions. This research must be oriented towards practical issues which will drive the eradication effort forwards and improve technical, operational, and fiscal efficiencies. Data must provide an empirical basis for decision-making, particularly when assessing the cost and cost-benefits of specific programmes.

Much applied research should be conducted prior to the launch of the eradication effort to ensure the accuracy of the approach and provide baseline information that can be used in monitoring the impact. Once efforts are under way, prospective research agenda should be developed to track impact, identify efficiency paradigms, and strengthen delivery. This research should serve to improve system quality, while fine tuning eradication interventions.

What does eradication bring to health programme financing?

• Additional mobilization of resources (both financial and human) at global, national and local levels, from public and private sources, for both additional (eradication-related) costs and basic service costs.
• Additional partnerships, including those committed to resource mobilization, leading to significantly greater numbers of volunteers and other people involved in health action.
• Attention to sponsorship and other innovative financing mechanisms.
• The capacities to identify progress and sustain donor interest in health financing.
• Clear end-points and time frames that minimize discussions of sustainability.
• Increased public visibility and support for health, including increased willingness to pay for health services, as well as increased international solidarity with global health issues.

What are the actual and potential dangers of eradication for the health system and health development?

• Diversion of resources (financial/human) from existing support to basic services nationally and internationally, and overall reduced attention to meeting the resource needs of basic services. Each activity that is employed in furtherance of an eradication objective may reflect an opportunity cost. These opportunity costs are significant in all health service systems, from the most sophisticated, where high levels of disease control may exist, to emerging health care systems that may be quite vulnerable to the diversion of scarce skills.
• Opportunities "foregone", especially in countries where the eradication effort has a low impact in terms of health outcomes.
• Potential decreases in resources available for research, both for the eradication effort and for other health problems.
• Failure to estimate accurately the needs of the eradication efforts, leading to subsequent "forced" diversions once effort is underway.
• Enthusiasm for eradication could lead to many simultaneous eradication efforts and induce failure.

Based on the above points, the following recommendations aim at maximizing benefits and minimizing dangers.

• Early planning for eradication and basic health services to accurately identify the costs and benefits. In particular, planning should include: long-term costs for strengthening the health system and additional costs for the eradication effort; evaluation of current budgets and capacities (national and international); financial and human resource needs; individual and societal benefits; cost-effectiveness and affordability of the proposed eradication effort; and specific cost criteria for evaluating the performance of the eradication effort (e.g. cost per child protected in various situations, by country).
• Articulation of the rationale and criteria for provision of external support for eradication efforts, which are not affordable from national sources, and mobilization of external resources, including the cost and benefit of eradication to industrialized countries. Many industrialized countries contribute significantly to resource mobilization for eradication activities; however, within some countries there may be considerable resistance to diverting resources from health service activities when initiating eradication efforts if the disease burden is perceived to be low and the opportunity cost of the attainment of eradication is perceived to be high.
• Early recruitment of partners, especially in the private sector, and identification of innovative financing mechanisms.
• Ongoing advocacy based on successes, to recruit new partners and resources, and assessment of public attitudes towards funding in both developing and industrialized countries.
• Mechanisms for ongoing and periodic financial review and resource coordination, review and updating of cost criteria.
• Ways of maintaining, within the health sector, any resource savings gained from eradication efforts (this rarely occurs since real term costs for eradication frequently fall to health ministries, while the health gains accrue to national treasuries or ministries of trade). Furthermore, increased public awareness as a consequence of eradication activities may lead to increased willingness to provide resources for basic services.
• Global, regional, and local resource mobilization reviews should be planned.
• Resources for eradication activities should be additional to those available for basic health care services and should not be provided at the detriment of existing services or those that are planned.
• A careful, transparent process for decision-making on new eradication efforts, based inter alia on the following: assessment of the global capacities for resources mobilization and financing; assessment of opportunity costs, at national and global levels; opportunities for public health synergy of different eradication efforts; and the need to balance the requirements of centrally driven goals with the potentially very different peripheral level priorities.

The Workgroup considered that eradication programmes have great potential to strengthen the capacity of health services by training health workers, recruiting community members for health improvement, and providing concrete examples of good management. It is often assumed that eradication programmes will improve human resources. While this sometimes happens, it would be more efficient to include capacity building in the design of eradication programmes. This would increase the probability that these desirable benefits are, in fact, achieved.

Explicit planning for capacity building will focus the attention of planners on potential negative features of eradication programmes, which could be avoided. While it is unreasonable to burden eradication programmes with improving the primary health care (PHC) package, these programmes should contribute to the maintenance and strengthening of health service structures.

Eradication programmes often create a brain drain by diverting talent and human resources away from PHC programmes. In response to these problems, the recommendations outlined below were suggested.

• Incentive systems that encourage and reward personnel to seek out and capitalize on opportunities for synergy and integration of health services with eradication programmes should be developed.
• Supervisory systems need to be able to reward integration.
• Eradication programmes must invest in building basic human infrastructure. There should be clear human development objectives in all programmes which should be evaluated to meeting human resource needs. Any new eradication effort must train and develop the human resource pool as part of the initial stages of capacity building for delivering the basic package of health services (e.g. HIS, logistics, training, and evaluation).
• Eradication programmes should not attempt to build temporary or parallel structures whereby human resources are fostered and then jettisoned.
• The district and community levels have a critical role in sustainability of services and successful implementation of eradication objectives. While the central level is also important, human resource development and training need to focus on those at district and community levels.
• If eradication campaigns need to be sustained and external support is not available, it is essential that they be integrated with local health provision capacity.

Eradication programmes tend to retain a hierarchical division of labour, with assessment and planning/policy skills at the national level and implementation of skills at the district or local level. Most developing countries are undergoing decentralization and are rapidly shifting responsibilities to the periphery for planning/policy development, problem solving, and health problem assessment; the present training infrastructure is addressing this growing need. Training curricula and infrastructure should be modified to reflect these changing roles and responsibilities. These include new skills at the local level which must take advantage of emerging technologies (e.g. the Internet, distance-based learning) to reach large numbers with standardized curricula. Eradication programmes tend to create parallel (and even redundant) training curricula and infrastructure which may be wasteful and not sustainable, and which work against the integration of functions. Based on these considerations, the following recommendations were made.

• Training in areas such as management (including that of quality assurance), leadership, and epidemiology should be generic and offered in integrated courses to employees from different health service backgrounds; this training should focus on the practical skills needed by workers to do their jobs. Indicators of the outcome of training should be linked to the programme's goals (i.e. programme achievements reflect training attainments).
• Training for eradication programmes should provide skills that can be used in implementing other programmes.
• Training programmes should have specific objectives in terms of impact, increases in programme output and competencies. Evaluation should be based on the accomplishment of these goals.
• Training should include skills for social mobilization, health outreach, health education, and health promotion.
• Training needs to have a practical component so that trainees bring real skills, not just theoretical knowledge to the job.
• Training must be appropriate for each level and should seek to minimize the boundary between community volunteers and beginners among health workers.
• Practical experience should be an important criterion for entrance into the health workforce and practical competencies should be a major criterion for evaluation.
• Training should be problem-oriented and focused on knowledge and competencies for improving health in the specific programme, but which can also be applied to other health programmes.
• Training should be designed and evaluated with clear objectives in terms of competencies and expected outputs.
• Training should include not only specific technical information, but also competencies in problem-solving, decision-making, and management in the health system. Training should include descriptions of the competencies required and constraints of the management level directly above the trainees.

Since eradication programmes may mobilize communities for eradication goals without building community support and capacity for other health goals, the points shown below should be taken into account.

• Social mobilization should emphasize that people are being mobilized for improved health, not just for a specific programme. Use of non-health personnel has long-term benefits in terms of sustainability and community support.
• Training that furthers the skills of social mobilization should incorporate wider competencies than those simply required for the eradication objective, and should be general rather than specific so that they can be used in the future for sustainability of health services after the eradication objective has been achieved.
• Health education should reflect community concerns.
• Eradication programmes should express their goals in terms the community can understand.
• The successes of health care workers and volunteers should be documented and given recognition.

There are intrinsic and unavoidable tensions between the concepts of eradication and sustainable health development. These tensions arise because of polarization between vertical and integrated approaches -- specific rather than comprehensive goals, "top-down" rather than "bottom-up" directions, and a time-limited rather than long-term agenda. It is essential to acknowledge and overcome these tensions so that eradication programmes can contribute to health development. In addition, the following beliefs and acts of faith accompany eradication programmes: first, there is a legacy of wider benefits than simply the achievement of eradication or complete absence of cases; second, the cost-benefit of eradication is greater compared with the achievement of high levels of control; and third, commitment must be made on the grounds of beliefs or, alternatively, further eradication endeavours must be postponed until the prerequisites can be confirmed.

Besides gaining insight into the technical feasibility of eradication, rules are being developed that create a discipline that was not previously acknowledged. These rules encompass resource mobilization, strategic planning, human resources and training, and social mobilization. Detailed, meticulous planning is essential to take full advantage of the opportunities created by eradication programmes, thereby avoiding the potential for unwanted, negative effects. However, the experience with eradication programmes to date has shown some of the limitations of the planning process.

Ideally, the potential benefits of eradication to health development should be identified at the outset. Similar to the eradication targets, measurable targets should be set for achieving these benefits. The eradication programme should be held accountable for the attainment of these wider objectives. Resources for eradication activities should be additional to those available for basic health care services and should in no way be detrimental to existing services or those that are planned, except in situations where the consequences have been carefully considered.

• Eradication programmes should not be held responsible for curing the ills of existing health systems.
• Eradication programmes should have two objectives: 1) reduction of the target disease to zero incidence, which can be maintained even when all intervention ceases; and 2) further development and strengthening of health systems, especially with regard to monitoring and surveillance, supervision, and programme management.
• Eradication initiatives should be implemented with the support of a broad coalition of partners; great efforts should be made to build consensus.
• Managers of eradication initiatives should respect the importance of other, ongoing public health programmes.
• To the extent possible, peripheral-level decision-makers should be allowed to reach centrally established targets in a flexible and locally appropriate way.
• Successful eradication programmes are powerful examples of effective management, building management capacities to be carried to other health programmes.
• Efforts should be made to design eradication programme activities that further the development of leadership and managerial and technical skills among health personnel.
• Eradication initiatives should actively participate in the development and implementation of effective surveillance systems which can be readily adapted to meet the needs of other national priority programmes after eradication is achieved.

It is essential for eradication programmes to include the following features.

• Training in management, quality assurance, leadership and epidemiology should be generally available and offered in integrated courses.
• Training for eradication programmes should explicitly cover skills that can be widely used; acquired knowledge and competencies have to apply to other health programmes as well.
• Social mobilization has to be for improved health, and not only for a specific programme, involving non-health personnel, because of long-term benefits in terms of sustainability, community support, and epidemiological surveillance.

It is essential for eradication programmes to avoid the following pitfalls.

• Capacity building without appropriate attention to health information systems and evaluation.
• Building parallel or temporary structures whereby human resources are fostered and jettisoned.
• Concentrating on the central level and overlooking the need to remember human resources at district and community levels.

The benefits eradication brings to health programme financing include those outlined below.

• Additional resource mobilization at global, national, and local levels for both further eradication and basic service costs.
• Innovative financing mechanisms (e.g. sponsorship).
• The capacities to identify progress and sustain donor interest in health financing.

Actual and potential dangers of eradication for the health system and health development include those mentioned below.

• Opportunities "foregone", especially for countries in which the eradication effort has a low impact in terms of health outcomes.
• Failure to accurately estimate the needs of the eradication efforts, leading to subsequent "forced" resource diversions once the effort is underway.

Early planning is needed to identify accurately costs (both long-term for strengthening the health system and additional costs for the eradication effort) and benefits. Planning should include the following.

• Evaluation of current budgets and capacities (national and international).
• Financial and human resource needs.
• Cost-effectiveness and affordability of the proposed eradication effort.
• Specific cost criteria for evaluation of performance of the eradication effort (e.g. the cost of a child protected for various country situations).
• A careful, transparent process for decision-making on new eradication efforts, based inter alia on factors such as assessment of the global capacities for resource mobilization and financing; assessment of opportunity costs at national and global levels; opportunities for public health synergy of different eradication efforts; and the need to balance the requirements of centrally driven goals with the potentially very different peripheral level priorities -- especially important when decentralization leads to district level autonomy in resource prioritization.

• Planners must assess the capacity of the current system to meet the requirements of the eradication intervention and identify opportunities for capacity building.
• Planning and design must maximize the partnerships of all potential stakeholders.
• Eradication must ensure the quality of delivery regarding safety, coverage, effectiveness, and efficiency.
• Any eradication programme must include "surveillance for action" -- both for eradication and for development of the surveillance infrastructure including all public and private sector stakeholders.
• Countries must carefully weigh the consequences of their eventual decision to adhere to an eradication initiative, and consider the value of strengthening their health systems as a contribution to the success of the eradication programme. Similarly, eradication initiatives can contribute to strengthening health services and these benefits should be identified whenever possible.
• Eradication should remain exceptional and be carefully designed to maximize the chances of success and positive effects for sustainable health development.

I should like to thank Dr Denis Broun (Chairman), Dr Victor Barbiero, Dr Ron Waldman, Dr Mark White, and Dr Roy Widdus for their special contributions to this report.

* Principal Medical Officer, Department of Health, London, England.

TABLE 1. Disease eradication and sustainable health development

Subgroup concentrations      

Core questions

• What does eradication strengthen?
• What does eradication risk?
• What synergies can be developed in eradication activities?
• Will the shift from public sector service provision for primary care and maternal and child health be significant for eradication activities?
• Given decentralization of responsibilities for public health, how will the momentum be achieved for eradication activities, when the central public health role has diminished?
• When responsibilities for resource allocation are delivered at the local level, in line with local health needs, how will global eradication priorities be "imposed" when they are not ­perceived as locally important?
• Will the greatest challenges to eradication activities come from those whose services are least well developed?
  • Will industrialized countries compromise eradication activities because they do not perceive the need to divert resources to diseases of little consequence to themselves?
  • How will they be influenced to accept the real and opportunity costs when they see little direct personal benefit?
  • How can commitment be assured in advance of establishing eradication goals?
  • Can we identify a set of prerequisites or preconditions that must be satisfied, before a new eradication goal is set? Is this worthwhile?
  • How can we ensure that quality is improved by the achievement of eradication?
  • Are there essential requirements that should already be in place before eradication activities begin?
  • What might such indicators be?
  • How can we encourage those for whom eradication activities might be the most difficult to be in the forefront? Should they be?
  • Can we make specific recommendations that will ensure that health care systems achieve the maximum benefits from eradication activities?

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