On February 25, 2012, the World Health Organization removed India from the list of countries with active transmission of endemic polio. This leaves three countries – Nigeria, Pakistan and Afghanistan – that are still struggling to eradicate polio from their population. (See our previous blog for a discussion of the difficulties these countries are facing.) India is an example of a remarkable success story made possible by hard work and meticulous planning. In 2009, India reported the most polio cases of any country in the world – 741. By the next year, the country reported on 42. The last case of polio in India was reported on January 13, 2011.
We can use root cause analysis to determine causes of problems, and to learn from the issues of others. We can also use it to learn from the successes of others. Here we can use “success mapping” to create a Cause Map, or visual root cause analysis, of a successful outcome – in this case, the eradication of polio from India. The steps of success mapping are the same as for incident mapping. In this case, the public health goal was impacted – positively – by the absence of polio cases since 2011 in India.
We begin with the impacted goal, and ask “Why” questions. The absence of polio cases in India is due to a successful vaccination campaign – covering more than 99% of children. The successful program is due to a comprehensive, detailed vaccination plan, which we can lay out in a process map. (To read more about India’s polio vaccination campaign, please see the Global Polio Eradication Initiative’s Website.)
The process for successful vaccination addresses some of the common problems with vaccination programs, which are still seen in the remaining endemic countries. Notably, access to children is a major difficulty with vaccination programs. In India, local volunteers canvass neighborhoods and determine the number of children in each home to provide vaccination workers with a number of children to look for and vaccinate. Vaccination teams are also provided special tracking booklets for newborns, to ensure that any children that were not previously accounted for are added to the total.
There are many reasons that children are unable to be vaccinated. Aid workers track the specific reason for each child that is not vaccinated and, depending on the reason, an appropriate follow-up team is sent to the house later on the same day and, if still unsuccessful, later in the week. Follow-up teams include a community influencer if a parent refuses to vaccinate the child and a medical officer if a vaccination is not given because a child is ill.
Because some children are not found at home, transit teams were formed. These teams vaccinate children at major intersections and transit points, such as train and bus stations. To ensure full coverage (and that each child is vaccinated only once), children’s fingers are marked after they have received vaccinations.
It is hoped that some of these ideas can also be used by the vaccination teams in the remaining countries that have endemic polio and to ensure that polio does not return to countries that have already been removed from the list. When ideas are successful at one site, other sites may be able to benefit from them as well.
However, a great process means nothing if you don’t have a team of dedicated workers. As stated by India’s Prime Minister, “The real credit goes to the 2.3 million volunteers who repeatedly vaccinated children even in the most remote areas, often in very bad weather conditions. I commend each one of them for their dedication, commitment and selfless service.” We second that commendation, and thank you for helping reduce the risk of this horrible disease.
To view the Process Map, please click “Download PDF” above. Or click here to read more.