How to eradicate polio in Pakistan: Insights from community health workers.

Pakistan, along with Afghanistan, is one of two countries where wild poliovirus is still endemic. Frontline workers (FLWs) are the staff most intimately familiar with both implementation challenges and community context. Harnessing their expertise may be a way to improve the community-polio program interface, which has been a persistent and shifting challenge in polio-endemic areas of both countries. From 2020-2022, we engaged frontline workers in 18 Super High-Risk Union Councils (SHRUCs) in Pakistan through a Human-Centered Design ideas competition. In that competition, teams of polio FLWs identified the most significant barriers they faced in conducting their work, and suggested solutions to those problems-a window into the issues the program faces by the people who know it best. The suggestions of FLWs on how to eradicate polio fell into four main categories. First, there were suggestions to tackle community fatigue by reducing touchpoints, particularly visits solely for data collection. Second, there were calls to improve Primary Health Care in SHRUCs, as a way of addressing community frustrations over an intense focus on just one disease in the context of numerous acute needs. Third, there were suggested ways to increase community engagement through locally relevant channels. Finally, many workers suggested improvements to Human Resources processes and workplace dynamics. Across these ideas, one repeated concept is the need for balance between the intensity of polio activities required for eradication and the provision of other government services, including health services. FLWs engaged the process deeply, providing well thought out problem statements and ideas for change. It is our view that there is no one more qualified to speak to the issues on the ground than FLWs. There are critical insights available if we listen to people who are instrumental to the success of health programs, but not commonly involved with creating policy.