Analysing the impact of the polio eradication initiative on routine immunisation in Uttar Pradesh, India

Embedded in the study of interactions between global health initiatives and country health systems, this paper analyses the impact of the Polio Eradication Initiative’s (PEI) on the routine immunisation programme in Uttar Pradesh, India. Applying the policy implementation framework and a mixed-method research design to analyse the PEI’s policy to “strengthen routine immunisation,” qualitative analysis demonstrates ambiguous translations of programme policies into operational guidelines. Trends in financial resource allocation and vaccine delivery logistics suggest that this ambiguity gives rise to a prioritisation of polio eradication at the expense of routine immunisation strengthening. This mismatch is supported by the quantitative analysis of household survey data from 2002 to 2008 (District Level Household and Facility Survey). Logistic regression analysis suggests that, within Uttar Pradesh, children with a greater exposure to mass polio immunisation rounds had a lower chance to attain full routine immunisation. However, such adverse policy outcomes need not be a general rule as a similar analysis for the state of Bihar yields more encouraging outcomes. One mechanism underlying these processes and outcomes appears to be the institutionalisation of mandates in programme implementation. In a health system context that assigns dominance to scientific knowledge and to influential stakeholder groups in health agenda-setting and policy-making, the National Polio Surveillance Project emerges as a powerful technical advisory body. However, its primary objective of eradicating poliomyelitis—rather than supporting routine immunisation operations—suggests a likely programme governance bias which contributes to the mismatch between the routine immunisation strengthening policy and its implementation. This paper suggests that global health initiatives do not leave health systems unaffected, which can potentially undermine the direct effects of the intervention. Policy implementation processes can contribute to such adverse outcomes, albeit their extent merits further investigation. To address the challenges of polio (and soon measles) immunisation in India, participation of non-technical stakeholders such as recipient communities in programme governance is advisable