Seeing What We Don't See: A Polio 'Hopes and Fears' Editorial

Busy medical, epidemiology, and immunization managers at district levels and above can easily get so caught up in managing logistics and reviewing data that they forget to make the time to go out and gather their own data by visiting static sites and observing field teams. Traveling in Africa and Asia with a polio Outbreak Response Assessment (OBRA) team was an eye-opening experience. None of us ever know what we don't know - managers who don't watch the work being done can't possibly know what performance gaps exist, and where there are opportunities to support staff and strengthen quality.

During recent assessment visits to two countries experiencing polio outbreaks, senior health decision-makers traveled with the OBRA team and saw for themselves, for the first time, the actual gaps in performances of campaign workers. In every instance, they were shocked, and then determined to make changes that would make a real difference on the ground. A colleague doing a campaign quality assessment in another province found that local district-level health workers traveling with her started copying her approach to monitoring what had been happening at campaign sites, asking questions they had heard her ask in previous locations.

In another location, very talented, well-meaning district medical and epidemiology officers weren't aware of the gaps in campaign performance going on in the village right outside their door. On the fourth day of the campaign, women who had been selling fruits and vegetables on the lawn outside the clinic had not been approached by any vaccination team, and the children sitting with them were unimmunized, although they exhibited no resistance when they were given the opportunity to have their children vaccinated. None of the mobile teams was observed approaching vaccine-eligible children or their parents; rather, they waited for parents to approach them. They also were not providing any information regarding the dangers of polio, the importance of vaccinating every child, the anticipated frequency of campaigns, etc.; in fact, they weren't engaging in conversation at all. The vaccination teams in the marketplaces did not ask about children who weren't present and might have been missed. Yet when the OBRA team members walked through the village with the vaccinators, actively offering the vaccine, dozens of children were vaccinated, and as word traveled through the village, more and more children and families began to approach the team. Slowly, the vaccination team members began to engage more proactively as well, mimicking what they had seen and heard from the OBRA team members.

Similar scenarios were repeated in many villages in that country and elsewhere. Significant investments are being made in training, but how much of these investments include the supportive supervision training that can ensure both real-time information on gaps in performance and the opportunity to close the gaps and ensure high-quality health service delivery? And do training programs that build managers' or supervisors' supportive supervision skills do so in a way that using them, at least in informal ways, becomes a way of life, applied not just to a specific project or a long-term program but to all activities, including unexpected ones such as outbreak response campaigns? If we are to eradicate polio and sustain the other achievements made in public health, we can't afford to fail in the area of supportive supervision.

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Ellen Coates, MPH is a public health professional who is former Director of the Core Group Polio Project and member of several recent outbreak response assessment teams in Laos and Madagascar. She has extensive experience in maternal and child health, immunisation, and polio eradication throughout the developing world, with a particular focus in recent years on communication for development (C4D) in the context of polio eradication and strengthened routine immunisation in Africa, Asia, and the Middle East.