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Table 1 Summary of challenges faced by the smallpox eradication, factors described in the published literature that enabled programmes to overcome them, and potential lessons for malaria eradication

From: “Remarkable solutions to impossible problems”: lessons for malaria from the eradication of smallpox

Theme Smallpox challenges Smallpox success factors Lessons for malaria
International support Lack of global political endorsement Backing from major global superpowers
Strong, well-connected central leader
Need to maintain public relations and advocacy for campaign
Limited profile and resources Engaging national leadership at World Health Assembly
Widely released report on progress and challenges
Maintain World Malaria Report as progress tracker and opportunity for visibility
Use global forums to hold political leadership accountable
International coordination Low quality products with stability issues at start of campaign Clear quality standards and reference labs for quality testing Maintain global quality assurance structures for malaria products
Unforeseen challenges necessitated ongoing innovation and research Decentralized innovation, including development of new tools and testing of new strategies, encouraged by the WHO Continue investing globally in research and development, while supporting countries to iteratively improve programmes based on quality data and analysis
Insufficient donor funds to donate vaccine to large-volume countries Local manufacturing of vaccine in large-volume countries Consider building local manufacturing capacity for high volume commodities like bed-nets
Lack of coordination or synchronization between regionally connected countries, and limited impact of international declarations Small financial incentives to encourage country participation
Technical and logistical support staff embedded in country programmes to help build efficient programmes following best practices
Embrace independent actions by countries as a way to test many approaches simultaneously across different sociocultural and epidemiological contexts
Use funding to encourage participation
Encourage countries to try context-appropriate strategies while encouraging uptake of proven best practices
Provide countries with embedded advisors to build both technical and operational/logistical capacity
WHO’s bureaucracy limited speed and agility of programme, and disparate views on approaches persisted between different levels of the WHO WHO staff took flexibility into their own hands to quickly respond, circumventing institutional rules and leveraging backchannels wherever possible Reduce bureaucracy in global and regional coordination mechanisms to ensure flexibility and nimbleness
Financing Resources were being used inefficiently in country Transitioning existing domestic resources to more effective management schemes to achieve greater impact without substantial budget increases Ensure optimal allocation of available funding and strong management and measurement to increase and demonstrate its impact
Interest in allocating funds to the programme waned with decreasing case counts Agreement that eliminating in low resource countries would reduce prevention costs in high-resource countries Continue advocacy efforts, including through business and political champions, to keep malaria a priority even as visibility wanes
Bureaucratic processes or insufficient funds created bottlenecks in paying staff and transport costs Flexible funding accounts and reimbursement mechanisms Increase availability of small but flexible funding that can be used to address bottlenecks across countries as they arise
National support Competition with other disease priorities limited support, particularly as burden diminishes or when less virulent strains were common
Government leadership turnover often led to loss of prior political support
Identification of politically-connected domestic champions
Engagement of private sector actors
Build external national support outside government, including identification of malaria champions
Create private sector partnerships to maintain elimination enthusiasm and support implementation
Community support Mistrust of vaccination due to real or perceived adverse events Engaged or combined mobilization and awareness efforts with other community initiatives (neonatal care, census taking, market days)
Gained community acceptance through proactive engagement with community leaders
Conduct community research to understand how to most effectively build support and engagement from affected populations
Single disease focus may have reduced community participation Used financial incentives in the endgame to keep up engagement and enthusiasm
Created private sector partnerships to extend vaccination and education efforts
Tie malaria elimination efforts to larger health system initiatives (childhood illness, community health, vector control) to increase participation
Compulsory vaccination approaches elicited negative reactions from community Discouraged compulsory vaccination Increase outreach at local level to village leaders to ensure community buy-in and cooperation
Programmatic strategy Transmission persisted in unvaccinated populations despite high overall vaccination rates Shift from national mass vaccination to surveillance and focused vaccination in the areas where smallpox was observed
Case finding intensified during the period of lowest seasonal incidence, the weakest point of the transmission cycle
Global guidance updated and disseminated by WHO as evidence accrued of what worked best
Focus on targeting prevention and treatment to the places where they are most necessary, rather than only evaluating the number of people receiving them
Understand malaria seasonality and ensure interventions are intensified at the time of the year when they will be most impactful
Continue to update technical and operational guidelines and encourage countries to adopt proven approaches
Disease reporting depended on independent statistical units and other health system entities not within the control of the smallpox programme Follow up and routine feedback to all reporting points to ensure good participation
Developed a network of agents who conducted active case detection activities
Integrated reporting from both health facilities and active surveillance to leverage strengths of both
Provide routine feedback and supervision to all reporting points to ensure high quality data
Augment routine reporting from health facilities with active surveillance designed to identify areas of transmission that may otherwise be missed
National programme structure and management Limitations of existing health system to achieve necessary surveillance and vaccination coverage of at-risk communities, but inefficiency and unsustainability of a fully vertical program Vertically managed and measured programmes were integrated with basic health systems, allowing smallpox-specific programmes to leverage horizontal systems for surveillance and support Leverage basic health systems for routine case management and ongoing surveillance
Integrate malaria elimination into the health system to improve functionality and cost-effectiveness, while maintaining vertical elements to facilitate fundraising, community mobilization, and political buy-in
National programmes tended to assess progress in terms of activity, such as the numbers of vaccinations performed, rather than the result achieved Clear, specific, and measurable goals drove a focus on results, with prioritization of quality measurement and verification over quantity Set clear, measurable targets related to specific reductions in outcome metrics, rather than only measuring the number distributed
Diversity of contexts and challenges meant no set checklist of methods for how vaccination campaigns and case finding should be carried out was possible Experimental learning and avoidance of formalized programming facilitated identification of local solutions
Problem-solver staff with reputations for adaptability, imagination, and hard work hired to serve as catalysts rather than controllers
Hire and retain strong managers and operations officers to ensure execution
Hire flexible problem solving staff with backgrounds not limited to technical areas of malaria and public health
Provide management training to programme leaders and aim for retention of strong managers
Supervision was insufficient due to workloads and insufficient travel into programme areas to observe problems WHO, national, and state or provincial supervisory staff encouraged to frequently travel into the field to review activities and work with field staff in resolving problems Encourage managers from all levels to spend as much time as possible working in person with local programmes in endemic regions