Reimagining polio eradication
Applying behavioural insights to reach 'zero-dose' nomadic communities
The last mile to end polio
Ahmed Bishar Duale was a ‘zero dose child’, unvaccinated, and contracted polio when he was 14. “I faced difficulties” he says. “I couldn't do what other people who were not disabled could”. The 38-year-old lives near Habaswein (meaning ‘Big Dust’ in Somali) which is a small town in Wajir County, Kenya.
Ahmed had six children but two died shortly after being born. He imagines a better future for his four surviving children, which requires protecting them from polio.
“My four other children are immunized… they are vaccinated so that they don't get the kind of disease I got” he explains.
Three cases of (vaccine-derived) polio virus were confirmed in Kenya in 2020 and 2021, all linked to the informal route through Habaswein, a stop-off point for nomadic herders near the Somali border.
Eradicating a disease, such as polio, requires 100% vaccine coverage. In Kenya, despite efforts to boost immunisation rates, the same 1% are missed again and again: the zero dose children whose parents herd livestock, searching for pasture along the dusty border with Somalia. This is a population vulnerable to climate change and conflict, shocks which always lead to disease.
Kenya’s recent drought (the worst in 40 years) has led to mass dying of livestock, incomes plummeting, malnutrition, poor sanitation and then, diseases. This is the sharp end of the 1% equity agenda. All of Kenya’s polio cases are located around this porous border.
Taking services to the people
UNICEF’s ‘DICE’ project, funded by the Bill and Melinda Gates Foundation, engages the community in order to intensify demand for vaccines. The team knew they needed to improve this nomadic community’s trust in the health service.
Timiro Ali Abdi is a mother of two children. She is also shopkeeper in a village just five kilometres from the Somali border. When pastoralists come to her remote shop for supplies, she tells them about the latest DICE activities in the area. She also feeds back information to DICE, so the health workers know which water points are being most frequently used. This is particularly useful intelligence during a drought response, when herders have to travel farther afield in search of water, and so are harder to reach.
One of this programme’s greatest innovations is to take the services to the people. No matter what, they will stop at certain water points, or in small towns where they can buy monthly supplies for the road. That’s where DICE sets up its outreach.
Barwaqo Bare Mahamoud, a mother of three, rides into the Bruke Nomadic Outreach Site on a donkey. Living within a deeply religious nomadic group, she relies on a community health volunteer for information about when the mobile health team is setting up nearby.
She says “If it were not for this service, I would have kept my child without immunization”.
A short history of vaccination services in Wajir county
Insecurity has increased since Kenyan government forces engaged directly in fighting insurgents, 13 years ago. Mohammed Dayib is a local nurse working with DICE near the border. He explains that “Health workers are not usually comfortable working in this border area because of the presence of terror groups.”
Timiro, the shopkeeper and mother living on the border, explains how the programme helps prevent insecurity from decimating health. There are some places on the border where vehicles can’t even go, you have to use unmarked cars. But because the drivers have a relationship with the community and are inconspicuous, health workers are not seen as a threat when they travel by this local means of transport.”
Ibrahim Hassan Abdi, County Director for Health in Wajir, backs this approach.
“Six whole new areas have been mapped and vaccinated. We are now working in areas we were bever able to access before. It was too dangerous to go in using a government vehicle, we’d be attacked.”
The genius of local knowledge
Ayub Duale is UNICEF’s Social Behaviour Change Officer. Being from the area, he spotted an opportunity to permeate this highly mobile community, by using a key player in their social scene: the Duksilow. The ‘Duksilow’ is a group of nomadic households who travel and settle together. The main structure of their congregation is the Duksi - the Koranic school formed of a religious teacher for small children from the households.
“If we can work with a focal person from the Duksis, mosques, shops and water points, we can coordinate where the communities are going to be and plan our services to meet their needs” says Ayub. “It’s the first time UNICEF has integrated services such as vaccines, malnutrition screening and birth certificates and taken them to nomadic settlements in this way.
“Some areas we have penetrated for the first time in 13 years [since the insecurity escalated]. And now there are no zero dose cases, since DICE started working here.”
No new cases
Ahmed Mohamed, an Imam and water committee chair, says “previously this community used to shun modern medicine, but as they border Somalia, and they see people coming over with measles and whooping cough, they can now see the difference vaccination makes. Sometimes you don’t appreciate things like good health until its gone.”
Somalia is one of the last few countries to eradicate polio, due in part to its crumbling health system and persistent insecurity. Kenya has a much higher rate of routine vaccination, broadly, but the coverage plummets as soon as you reach populations living near the Somali border.
Ayub makes it all seem so obvious. “The mapping was pretty easy. We just needed a smart phone and an app to geotag locations of nomadic settlements, water points, markets and duksis. We created a database and more than 100,000 people fed into this programme”.
But without this innovative thinking and extensive contact list, it would not have been easy to reach these ‘zero dose’ children. DICE has mapped out the way to eradicate polio in Kenya – and globally - once and for all.
