.. most things as you know in the pursuit of the millennium and development goals, much of what we have done so far has been giving more things to the same 70 or 80 percent of children and let this talk is going to be about is what we have learned of

trying to reach the other 20 or 30 percent of children and not only then bringing to the third reason about why eradicating polio, the third reason is not just to get there to eradicates polio and put these kids on a map but also to establish the structures, infrastructure, the processes and the support for going to scale in the areas where we need to get other interventions to achieve these and these are a few examples of what we have been doing well eradicating polio whether delivering bed nets, helping with the effort to eliminate measles or fighting pandemic blue. a few words on what global polio eradication initiative is -- it is a partnership first and foremost on the right-hand side you have some of the private sector partners who are part of its dash on the left side of the eradication initiative and on the right some of the political ngos who have played a critical

role in the program and, of course, at the center of this spearheading partners and ministries of how that have over the last 20 years been responsible for reporting the implementation of the eradication strategy is. these are four fold as you see here consisting of a base of routine immunization on which two conduct national immunization days and eventually mop up activities to interrupt the remains chains of polio transmission. to give you a sense of the scale of the program we are talking about from which i'm going to take some of the lessons this has been running for nearly 20 years, 20 and a half years actually and operated in over 200 countries over 20 million people involved in the eradication initiative and either distributing the vaccine coming immunizing children are supporting another ways and over 2 billion children have been immunized probably with close to

20 billion doses of vaccine. it is a partnership that continues to grow, to change and adapt to the nature of the disease, the epidemiology and the challenges we face. as you see from this statement by the president last week in cairo. now if we look at what has been achieved just before we go on to some of the lessons, this is what the world look like in 1988 when the global initiative to eradicate polio was launched and the commitment was made to get beyond the 80% that had been achieved in immunization coverage globally by that time and to reach that final 20 percent of children. this is where we were 40 years -- sorry, nearly 40 years after the vaccine have been developed and was widely available in the industrialized world to concede that children are still being paralyzed in vast majority of

the countries and nearly half million children a year. as a result of the implementation in eradication strategy is the disease was eliminated from all but four countries in the world by 2004. at that point the world got stock with of four parts of these countries, northern nigeria, northern india and parts of pakistan and afghanistan and then the situation got further complicated when the virus began to spread at of those countries and back into countries that have been polio free. so at this point in the program we face really four major challenges. in afghanistan and corners of pakistan as a noun, active complex as well the challenge of insufficient political body and in some corners of pakistan in particular and in india and very different problem and with insufficient mack's ineffectiveness which i will come back to as we go through the presentation.

and then in northern nigeria a combination of problems related to both buy in of the political leadership at different points in the program and the societies in which the program was operating. the whole thing than complicated as i mentioned by recurrent importations into areas that have been polio free. in addition to the four countries that you see. red, and other 15 countries this year alone were reinfected by spreading from these few countries. so this is where we are, that is with the eradication program is here and what i would like to do now is to look at the lessons we have learned before returning to what we're going to do to try to get the job of eradication finished. now, as i was pointing at that talk together, i shared with a few friends and they said you need to talk about partnerships and the power of partnerships and i said actually i'm going to presume partnerships basically as we look at what we're doing

because whether the partnerships that we have with groups like the global health council and with others that is the way that will be working in the future as we whether within the u.n. or outside it seek to improve the health of population so i am presuming that wheat will be working in partnership. the other thing i am presuming as well is whenever we are pursuing will provide opportunities for strengthening health systems and not going to talk about that either but i'm going to focus on the lessons that i have taken away from the 15 years in the eradication program as to what we have learned about getting beyond the 67 a percent of children we usually reach and what it takes to get to the end of the road so to speak and raised the children who because of differences of culture, religion, security, geography or whatever are not being reached to the most basic

of health services. the first lesson i think over writing is to bring a professional management. i am a doctor, i was trained to take blood pressure, trained to look a sore backs and things like that -- i was not trained in my professional training to run international health programs and the first thing i did in coming to the program in who was to hire people who didn't know how to do this -- the first person was an mba in the second was an mba, the third person was a communications officer, the fourth person was a lawyer, the first person we got rid of was also a lawyer. [laughter] but what we learned very early on was that in managing a program like this you have got to rely on people with management expertise and when we talk about -- these are a couple of shots to keep you. -- interested. as we talk about management the need to go beyond simply hiring the people but also putting in

place the management processes used to run a company and to run another organization. we need to bring that to public, as well and what we find so often, of course, is people bring in management people but then not the processes and it sort of like saying i have a democracy because i have a elections but i don't have the checks and balances and you have to have the whole shebang. in the polio program just as one example the measure everything in again this is a legacy and a global program especially in the americas and began a process today of measuring absolutely everything to maximize efficiencies but also to maximize accountabilities. there is a terrifying timidity in international public health to hold people accountable and this is something that we have got to get over as well. i probably shouldn't put in as a

specific lesson but if we were to accept the kind of shot a sometimes accountability of public health in the area of mechanics most would not stop in the morning. we need to hold people accountable to the process indicators and the goals that we put in place. this is an example from pakistan. a year or two years ago we went to the leadership of pakistan and said we need your help to hold people accountable in the eradication program and get the job finished and he asked for a map showing where the problem was and somebody handed a map but it was all green and what a show was over 95 percent of children were getting vaccinated in every district of pakistan and he said i don't understand the problem so we obviously were not properly managing the program. we went back and said it doesn't count if you say you were vaccinated -- you have to have a purple martin your figure, every

single campaign we mark the figures and then we look at that to see whether or not there are truly being vaccinated and a very different picture when we brought him and put in place to objective measures as to whether or not children were being vaccinated. by february of this year the prime minister announced his action plan to hold a leadership of its district accountable to reaching the children with the most basic of pelts services and then he put in place on the bottom mckenzie polio patrol from and a red sticker across the bottom showing this district leader has failed to vaccinate his children and people with phone in and say my district leader is neither and very quickly things started to change but again basic management processes have to be in place and you've got to close the loop and hold people accountable and we don't do that enough in public health. the second thing and i try to plug some of the things that are maybe a little if not controversial lobbying practice

in the second thing you need to do i believe at this point with the experience is you have to invest heavily on the ground type of assistance. we all want to buy a bed nets, we all want to buy vaccines and contribute that way, but in many of the places where we got to operate with the children being messed is because of the basic capacities are not there to be able to manage the resources you are putting at their disposal and need to invest in building that capacity. polio eradication is the easiest task you're going to have. to jobs in every single child, even i've done it successfully and we still need to put a lot of people on the ground. here's what we did in the polio eradication program -- guess what year i was hired? but when i ever arrived in geneva and looked at what we're trying to achieve it was quite clear we simply did not have the

personnel and expertise on the ground to put in place the basic management processes. this is something i discussed with malaria people in everyone else who uses these 3,000 people we have put on the ground because there seems to be a terrible the states but quite frankly without people on the ground to manage the resources and build the capacity you are going to learn by trial and error bristling with a lot more air the trial. this is the current distribution and this is a big challenge to the u.n. agencies you got to have the right distribution and mix and be able to move people and that is the thing we are very good at but as you can see here at least now the distribution of people reflects the epidemiology and the risks to the program. the other the thing is to be able to be flexible and respond with your human resources to

where your problems are. this is the last reservoir we believe of type one polio in india and this when you see is the cozy river coming from the north, then along the bottom uc the ganges river running and this is where the to me to. the area around the river is a massive flood plain a basically every time you see india flubbing vc people standing on the ropes were looking at this part of india on tv and this also as you can see is where polioviruses are right along this area mapped airily and when you look at what was in place to serve these people and manage the program there was one primary health care center with in the flood zone area. for an area of about 100 kilometers long and 20 miles wide and i think 10 million people during the flooding times so you need to be able to put in

place if you want to deliver an reach these children you have to help put in place the infrastructure to do it. this is what our team in india.com laying right on top of that virus then lay down very quickly a whole infrastructure to deliver not just the polio vaccine routine vaccinations, other basic interventions so you have to put that infrastructure in place. the third thing and i was so glad actually speaking to the memory of backwaters and her work, you've got to establish a robust capacity for all aspects of communications. this has become one of the biggest most diverse parts of our program which i'm not going to go through in detail but just give you an example of a couple of points, i spoke to one of our team in india who sent me this. it asked for his reflections on the role of communications and polio and you can see what he said here is it is required to think differently about the

communities and especially in this case the muslim communities where the disease predominated to understand the networks etc and then to be able to penetrate than that and engage with that committee to develop the perseverant needed to make real change and relearned a lot of other lessons as you can see, but to see toward the bottom something we have not been good and i think one of the things we learn from the polio program and the second to bottom was the importance of scale when it comes to the communications side of what we're doing. we still are technical assistance and refrigerators and our vehicles and everything else and try to run the communications on the pistons and often as an afterthought. what has become very clear is that certainly to finish eradication, to reject these populations we had to invest very heavily and had to make sure it was dated driven

everywhere we build our communications capacity. had to be in response to who we had to reach and what we were seeking to achieve there. this is a map to show you the scale of what we had to put in place in northern india to work with the muslim community to engage them and the underserved communities in seeking not just polio vaccine but any vaccine. they were best vaccinated against polio in iraq and as you can see we put nearly 5,000 part-time people on the ground, people from within the communities we trained on social mobilization, interpersonal communications etc. to begin the process of building the community engagement needed to be able to eradicate polio to get the population immunity up to the levels that will stop transmission. as we worked with the underserved communities to engage them as well this

required use of another tool we weren't used to, certainly in the immunization in the areas i have been working in and that was the widespread use of social mapping to figure out how we reach these populations. for those of you to medications are probably second nature and for those of us who are doctors and used to approach to medical problems and other way a lot of this is to a certain degree new but this is an example you see here from the tribal areas of pakistan border in right on afghanistan and as you can see they have mapped out the long the different parts of this travel agency were at them radio reaches, where they have taliban meetings, etc. to be able to mobilize and engage the committee so increasingly more and more sophisticated social mapping to figure out where the people are and what they will respond to. and the other thing is being again professional management, accountability and what we're

doing in the area of communications. of this is an example of using indicators to monitor what is happening in terms of our social mobilization impact. in august and july we began investing heavily in terms of community mobilizes in this area of karachi and then you can see we track overtime what happens in terms of refusals. and then finally the need to develop against special strategies for a very specific issues. as you can see here, not everyone thought polio eradication was an absolutely wonderful idea and we had to adapt our strategies as we went forward to deal with these issues and to ensure that communities were fully engaged. again, using locally a proper mechanisms with a committed a dialogue in northern nigeria and india to achieve that too. this brings me to one of the for

a big lessons we learned and this is the lesson in terms of advocacy. i think we are getting extremely good in the world of international health at national advocacy, international advocacy, the advocacy of that rock stars and heads of state but the reality is that all race awareness of what we're trying to do it and may raise resources but will not necessarily get the children vaccinated. in the big federal republics where we are working now, we need to be operating at the sub national level and this is an area that we are not very good at but when you look at where polio exists in india, for example is to northern states, there are too cheap ministers who between them and what would be running the sixth largest country in the world if it were independent, 350 million but to engage with people like this to

affect change in the states you have got to be able to advocate and some national level. what happens with the u.n., for example, we engage to the national level. ambassador circuit the national level and rock stars 10 to work at that level as well and what has been impressive when we look at one of the lessons from the polio program has been our ability to work or to learn to work at the some national level. i think what is -- these are probably some of the most impressive photographs from the eradication program. on the far left to have the director-general of who not meeting with the prime minister of india because that wasn't the key to revocation but the key minister travelling to where she was based and understand or the challenges and how do we help. similarly in the bottom picture here she is on the border of pakistan with the governors and the leadership of that key province. this is a picture of mr. gates's

trip to nigeria earlier this year, he went up north and met with the leaders of the traditional leadership, the sultan of sokoto and that with the nigerian governors, not with the president of the governors to help the two lavers to control in the vaccination of children in those areas so again not just advocacy we all talk about but advocacy of the level where it will make a difference in getting kids vaccinated. you've got to get to the some national level and there aren't a lot of mechanisms for doing it. we're not bad at mapping that politically, not good airplane and you can advocate with those players that effectively to engage in international and national goals, but it can make a very big difference. one of the major milestones and eradication initiative recently passed was when the governor will you remember stopped polio vaccines in his state for over 12 months in 2002 leading to the

biggest international outbreak of polio we've seen in 50 years. and for reasons related to concerns of public confidence in the safety of the vaccine, you can see. january of this year he vaccinated his own child against polio and using the vaccine to help restore that committed the confidence and get this moving faster. you can see this can i to advocacy of the seven national level -- this was five years after the national leader. >> on board and this is what made a difference. we have seen a drop by nearly 75% the proportion of his kids in the first quarter of this year as a result of his direct engagement and leadership on that. there are many myths about the polio eradication program, anything that runs this long is going to generate myths about one is the fact we don't do research and i think one of the most important lessons has been and then need to maintain an

active research program and that is the image we have done and the lesson we would suggest is for the question in terms of the title is to maintain research program especially if you thank you know all the answers. with the polio eradication program began in 1988 saying we have proved polio can be eradicated. all you have to do is apply the same strategies and the disease will be eradicated. their approaches are different and what is acceptable is different when you need different solutions. he will constantly be surprised especially in eradication and alan guess as we go for universal coverage of anything as you get out to the periphery geographically and culturally epidemiological a, the disease will surprise you, and you need a research program that can adapt to that.

a couple of examples within the program 20 years after the initiative was launched weaver introducing important new tools and vaccines for introduced in 2005 after six months development process things to our friends who took it on with 50 million disorder, probably smallest ever and decided to help us do this and then similarly lab procedures were implemented in 2006 that a cut in half the time needed to eradicate polio. a feeling that the application of these tools on the left-hand side we see the maps in indiana -- india -- to the one area of india that have never stopped polio. this area -- over here is in the area of the country which every other virus that we found sins of the year 2000 is genetically

linked said that has been a key reservoir three never stopped polio. we developed the vaccines and put in place tactical shifts and as you can see the beginning of 2008 by then we had gone a full 12 months without polio in that area. but it got real infected and are still trying to clear out but the research generated the solutions to it very late in the game is often the problem. three other big lessons we learned along the way. the six is probably the need to have money to reach the kids and the last when a person in particular but what might not be as obvious is the need for sophisticated fund-raising advocacy it around this not just lists some supporters but riposte diverse funding streams. if we look at the police programs this shows you a

breakdown of where the $7 billion have come from a beer you can see 40% from g8 and a multilateral sector about 12 or 15%. a private sector fully 20% and a domestic resources means actual cash into the program and about 14% and non gao and others about 5% of their resources so quite a diverse mix and if you to look at this program of the financial structure at any time you receive a changing to radically to adjust to the realities of who can pay for what went and who is willing to pay for what when. there is still is substantial finance the next two years as you can see a $345 million this by the jim and his generosity of these players. particular you see in the big orange block at the bottom rotary international which has

played an extraordinarily special role in the program not just as one of the initiators but in bringing both financial resources, political advocacy and volunteerism on the ground to getting the job done. again the importance of having a diverse range of funding is reflected i think in this graphic here. this shows the trend in g8 contributions since 2005 in polio eradication and in 2005, not since 2005 s shows you from 2003 through 2013 but the recent 2005 is important is because that was a year of the glen eagle summit in the u.k. and which the g8 made a commitment to sustain or increase its contributions to polio eradication until the job was finished and that was in 2005. as you can see the proportion in the mid that commitment as a proportion of the contributions

to the program. as you can see they went from a peak of 62% with the overall funding to 43% of overall funding in 06 and 08 and down to 20 percent of what is confirmed in the current time for the program so you've got to have a place not just a very aggressive advocacy agenda to maintain your funding streams but also other funding streams to adjust for problems like this. in the seventh lesson was protect your gains -- as a move toward an international public health we have a terrible habit of moving on to the next thing in taking our attention away from some of our successes only to see them to window again and perhaps the most riveting example of this in polio eradication is that we have not been able to protect a lot of the polio free areas because of chronic gaps in routine immunization services. you can see here the spread

internationally of polioviruses from india and nigeria just in the last five years and this is resulting in over 30 countries getting reinvented at one point or another and costs over a ton to $50 million in an outbreak response activities alone. protecting our gains, more attention should have been given to retain the immunization services of many people say why didn't you just continue polio campaigns in these areas. we did is to the short answer. for countries, condo, sudan and chad in the month have been chronically polio infected and between them they have done 150 polio campaigns in the last seven years. polio campaigns don't replace routine immunization services or adjectives to especially when getting bombarded by importations so looking for and we do have sans use in place