GPEI-“I won’t stop working until every child is protected”

Last month, Afia and her colleagues vaccinated 9.9 million children and educated millions of parents about vaccination across the country. © UNICEF Afghanistan

This is southern Afghanistan. A place characterized by a rich, diverse, but often complex history. Enveloped by mountains, this part of the country has seen years of conflict which have left hospitals under-resourced and health services shattered. Children face many challenges – as well as conflict and poverty, southern Afghanistan has the highest number of polio cases in the world.

In this difficult environment, the virus can only be defeated if every child is vaccinated.

Afia holds a young child who has just received a polio vaccination. The polio eradication programme is one of the biggest female work forces in Afghanistan. © UNICEF Afghanistan

Afia (not her real name), who is nineteen years old, is one of over 70 000 committed polio workers in Afghanistan, supported by WHO and UNICEF. Last month, she and her colleagues vaccinated 9.9 million children and educated thousands of parents about vaccination across the country.

The polio eradication programme comprises one of the biggest female workforces in Afghanistan: a national team, all fighting polio. Some women work as vaccinators, whilst others, like Afia, are mostly engaged in education and social mobilisation efforts. The polio programme gives women culturally-appropriate opportunities to work outside the house and engage in their community, speaking to parents about the safe, effective polio vaccine, and answering their questions. Often, women vaccinators offer other kinds of health advice, including recommendations for good child and maternal health.

To be a good vaccinator and educator, women must be committed to better health for all, with strong communication skills. They must also be organized to ensure that every child is reached during the campaign.

Afia says that if she wasn’t eradicating polio, her parents would expect her to give up her education and get married. Her younger sisters look up to her, excited to work in the polio eradication programme when they are old enough.

Her job is very important to protect all children. Afghanistan is just one of three countries – the others are Nigeria and Pakistan - that have never interrupted poliovirus transmission.

Women can vaccinate children who might otherwise miss out. Culturally, male vaccinators are unable to enter households to administer vaccine, causing difficulties if young children are asleep or playing inside. Their freedom to enter homes and give the vaccine to every child is one reason female polio workers are so critical.

Afia started work at 7 am, and is now walking home ten hours later with a young boy she has just vaccinated. Her purple burka stands out against the sand as she goes home to tell her parents and siblings about her day.

Afia feels positive about the future of polio eradication in Afghanistan: “We have a duty to protect our children, and I won’t stop working until every child is protected.”

Women have a right to participate in all aspects of polio eradication. Removing barriers to women’s full participation at all levels is a key goal for the Global Polio Eradication Initiative (GPEI). To learn more, see the gender section of our website, and read the GPEI ‘Why Women’ Infographic.

Afghanistan is just one of three countries —the others are Nigeria and Pakistan — that have never interrupted poliovirus transmission. © UNICEF Afghanistan

Bella smiles as she vaccinates a small baby against polio – one of hundreds of children she will protect over the course of a campaign. © WHO Somalia

Somalia, which stopped indigenous wild polio in 2002, is currently at risk of circulating vaccine-derived poliovirus type 2, after three viruses were confirmed in the sewage of Banadir province in January 2018. Although no children have been paralysed, WHO and other partners are supporting the local authorities to conduct investigations and risk assessments and to continue outbreak response and disease surveillance.

Underpinning these determined efforts to ensure that every child is vaccinated are local vaccinators and community leaders – nearly all of whom are women.

Bella Yusuf and Mama Ayesha are different personalities, in different stages of their lives, united by one goal – to keep every child in Somalia free from polio. Bella is 29, a mother of four, and a polio vaccinator for the last nine years, fitting her work around childcare and the usual hustle and bustle of family life. Mama Ayesha, whose real name is Asha Abdi Din, is a District Polio Officer. She is named Mama Ayesha for her maternal instincts, which have helped her to persevere and succeed in her pioneering work to improve maternal and child health, campaign for social and cultural change, and provide care for all.

Protecting all young children

Working as part of the December vaccination campaign, which aimed to protect over 700 000 children under five years of age, Bella explains her motivation to be a vaccinator. Taking a well-deserved break whilst supervisors from the Ministry of Health and the World Health Organization check the records of the children so far vaccinated, she looks around at the families waiting in line for drops of polio vaccine.

“I enjoy serving my people. And as a mother, it is my duty to help all children”, she says.

For Mama Ayesha too, the desire to protect Somalia’s young people is a driving force in her work. A real leader, she began her career helping to vaccinate children against smallpox, the last case of which was found in Somalia. Since then, she has personally taken up the fight against female genital mutilation, working to protect every girl-child.

She joined the polio programme in 1998, working to establish Somalia as wild poliovirus free, and ever since to oversee campaigns, and protect against virus re-introduction. In her words, “My office doesn’t close.”

Working in the midst of conflict

The work that Bella and Mama Ayesha carry out is especially critical because Somalia is at a high risk of polio infection. The country suffers from weak health infrastructure, as well as regular population displacement and conflict.

For Bella, that makes keeping children safe through vaccination even more meaningful.

“Through my job I can impact the well-being of my children,” she says. “For every child I vaccinate, I protect a lot more”.

Mama Ayesha echoes those words when she contemplates the difficulties of working in conflict. For most of her life, the historic district where she works, Hamar Weyne, has been affected by recurrent cycles of violence and shelling. With her grown children living abroad, she could easily move to a more peaceful life. But she chooses to stay.

“This is my home, and this is where I am needed. I am here for my team, and all the children.”

“I am the mother of all Somali children. I am just doing my job”. © WHO Somalia

Ongoing determination

Looking up at a picture of her husband, who died many years ago, Mama Ayesha considers the determination and courage that drives her, Bella, and thousands of their fellow health workers to protect every since one of Somalia’s children. Behind her thick wooden desk, she is no less committed than when she began her career. “If I had to do it again it would be my pleasure.”

Bella has a similar professional attitude, combined with the care and technical skill that make her a talented vaccinator. Returning to her stand below a shady tree, she greets the mothers lined up with their children. As she carefully stains the finger of the first small child purple, showing that they have been vaccinated, she grins.

“I am the mother of all Somali children. I am just doing my job”.

Mama Ayesha, a leader of eradication efforts in her district, considers what drives her work. © WHO Somalia

For more stories about women on the frontlines of polio eradication

Over the years, the Polio Eradication Initiative has been a vehicle for the empowerment of Nigerian women economically and socially. In recent times, this positive development has gained more impact with the timely and direct disbursement of funds for payment of vaccination personnel allowances down to grassroots level.

Over 360 000 vaccinators are engaged to support one round of national polio campaigns, and a further 180 000 for a round of sub-national campaigns. Out of these figures, over 80% are in the northern part of Nigeria where 100% of House-to-House teams are females. In addition, 100% of the supervisors are women. Further profiling of personal for all vaccination teams (including fixed post and transit point teams) indicate that 62% of the vaccinators are females. The findings also showed 88% of them have mobile phones for timely alerts and payments.

Interestingly, most of the female vaccinators are pooling their mobile money so they can have a bigger amount to kick-start their small-scale income generation projects.

“I have been able to successfully establish a business from stipends received from polio campaign and now have a source of income. I acquired a shop, bought machines and fabrics and now, I am the local tailor in my community,” Malama Amina Mohammed, a polio vaccinator team supervisor in Zamfara state mentioned.

Touching lives

There is considerable anecdotal evidence from WHO Nigeria Kano, Katsina and Kaduna state field offices that the huge investments by donors and partners have gone beyond polio eradication to impact positively on the lives of women, thereby enhancing equity.

Happy Gabriel is a student at Kaduna Polytechnic. She became a vaccinator three years ago after gaining admission for her diploma course. Polio programme stipends assisted her to concentrate on her studies and helped greatly to buy books and for her upkeep.

Appreciating the stipends received from SIAs, Happy stated, “I am deeply indebted to the polio immunization programme especially the initiative of Mobile money which eliminates delays we hitherto encountered at payment sites and equally engenders transparency.”

Very soon, Ms Gabriel will obtain her Ordinary National Diploma certificate from an accredited Nigerian institution and be gainfully employed even when polio is finally eradicated.

Asiya Ibrahim in Dala local government area of Kano is a widow. She has been a vaccinator for over six years. She lost her husband shortly before joining the polio programme. The stipends received has been helpful to sustain and keep her house together, including the upbringing of her children such as schooling, feeding and clothing.

With the frequency of the polio campaigns in the north, stipends received after each round cushioned the effect of losing her husband as she is always engaged in some form of activity.

Direct Disbursement Mechanism

Prior to 2004, operational funds to support SIAs in Nigeria were deposited by partners in a central dedicated account managed by the central government agency responsible for disbursement of the funds to vaccination teams. This mechanism faced a number of challenges including under-payment or non-payment of end-beneficiaries, delays in payment and retirement and inadequate documentation.

WHO conducted a risk assessment in 2013 and then established the Direct Disbursement Mechanism; an innovation that is considered a best practice and emulated by wide range of stakeholders.

With the innovation, the polio programme has helped to build up lives of vulnerable and economically disadvantaged personnel, especially those of women especially in poverty-stricken villages of northern Nigeria. The allowances after each round of SIAs have made them responsible to their immediate families and environment.

Polio interruption impossible without women

While monitoring the February 2017 round of SIAs in Kano, Dr Wondi Alemu, the WHO Country Representative, underscored the important role of female vaccinators who “are doing a marvelous job of fighting polio by negotiating and engaging with parents even when on transit. Without these women, the fight against polio will not be completed in Nigeria. The mothers trust them as they use techniques, including gestures and understandable language to convey much more meaning that easily persuades erstwhile resistant caregivers”.

Dr Alemu strongly feels that one lesson learnt from PEI is that the success of any public health intervention in Nigeria, especially in the north, hinge on the active participation of women who have empathy and patience to deal with diverse human emotions.

Additionally, through numerous training schedules and other activities organized by WHO and other GPEI partners preceding SIAs round, women’s skills have been empowered. Such skills as interpersonal communications skills, including negotiations have immensely contributed to resolving non-compliance to the oral polio vaccine among difficult to convince populations in northern Nigeria.