Pakistan is one of only two countries in the world where the poliovirus is still endemic – the other being neighbouring Afghanistan.
Since 2015, Pakistan has reported 362 polio cases, including 13 this year so far. One of the victims, a two-year-old boy, died in May, while some others have been paralysed.
This year, six campaigns, targeting over 43 million children, have been undertaken.
However, despite administering more than 300 million doses of oral vaccine annually with the help of at least 350,000 vaccinators and an expenditure of more than $9.3bn from 2013 to 2023, the country has been unable to eradicate polio.
Al Jazeera speaks to Dr Hamid Jafari, WHO’s regional director of polio eradication, on the current situation and the prospects of Pakistan eradicating polio.
Al Jazeera: How have things been in the last decade and where are we now?
Hamid Jafari: Over the last decade, the polio eradication effort has gone through multiple ups and downs. Polio is an epidemic-prone infection and disease. If you don’t eradicate it, you will see sporadic outbreaks. That’s why Pakistan and Afghanistan haven’t succeeded in stopping its transmission. They go through periods of very few cases and detections and then there’s a resurgence and you get an outbreak.
There are often events that are political or security related or a decline in programme quality that leads to an increase in the number of under-vaccinated children and then you get an outbreak.
In the last 10 years, we’ve seen strong progress. In 2020, there were around 12 genetic clusters. Now only two have survived. One on the Pakistani side and then there’s the YB3A in eastern Afghanistan.
It looks like the YB3C in Pakistan is on its way out – it was last detected in November 2023. But we’ve seen a resurgence of YB3A that has crossed into Pakistan. This is a cluster we’re picking up extensively in the southern region of Pakistan. 
Al Jazeera: Will that be easy to stop?
Jafari: The challenge exists in southern Khyber Pakhtunkhwa province. This is where there’s a lot of militancy, insecurity and community hostility and frustration towards the government because of conflict and a lack of services.
Now, more than 50 districts across Pakistan are detecting the virus. The challenge is to ensure they properly map these migrant and mobile communities and vaccinate them while they’re moving. More importantly, vaccinate them when they come and settle around these big urban areas and cities.
Al Jazeera: So you’re saying that the mobile Afghan population and the forced deportations are affecting the campaign?
Jafari: The programme was kind of prepared and took steps to engage with these communities. There may have been isolated incidents of communities not opening the door or being concerned but the programme is very mature, many of the vaccinators and supervisors are from the same communities.
So this was part of the trust-building process. Some of the community members moved in ways that were unpredictable and non-traditional. It has had somewhat of an epidemiological impact in terms of how the virus has spread because of some unpredictable movement or sort of unusual pattern of movement but I did not hear a big concern and the data doesn’t point to that.
Al Jazeera: What about the boycotts that you mentioned? What’s the impact?
Jafari: The quality of health services is poor in those areas. The quality of civic services, schools, roads and infrastructure is also poor. So they figured out that polio is a big priority for the government. So they sometimes boycott vaccination campaigns with demands that have nothing to do with immunisation or polio vaccination.
The programme implements health camps, additional stuff like soaps, hand-washing, hygiene, detergent, vitamins and other immunisations, but it cannot provide health services or education on a large scale.
Al Jazeera: What other kinds of pushbacks are being seen?
Jafari: The refusals come in many forms and manifestations. The more the programme matures, the more sophisticated and complex the refusals become. In large urban areas, people are saying our children are fully vaccinated, we have our private doctors, so why do you keep coming?
Then you have what we call soft refusals. People say you came last month, why are you back here? Some are a little harder to convince. That’s where local influencers come in, whether it’s a mosque imam, a local pharmacy person or a community leader, they talk to them, have a dialogue, and the community agrees. Then you have a group that just says no, saying they’ve had enough doses or they have misconceptions that this is about population control, haram and is a Western conspiracy.
There is a global anti-vaccine movement, especially around COVID, and that has not helped.
Al Jazeera: We’re also hearing about fake figures. Is that being seen a lot?
Jafari: Some of these communities are migrant communities. The programme has worked very hard to get trusted vaccinators, who speak the same language, are from the same tribe, culture, neighbourhoods. Over the last 12 months, the programme has uncovered collusion. The family tells the vaccinator to just mark the child’s fingers and not vaccinate.
So we are trying to unpack that dynamic. What kind of pressure is leading our vaccinators and the communities to collude like this? It’s obviously the pressure on the worker to demonstrate that they vaccinated everybody. So these hardcore refusal families, to avoid repeated visits, do these things. 
Al Jazeera: The other issue is the targeting of polio workers and security officials. Why is that still happening?
Jafari: Over the last few years, it is not the polio programme being targeted but the security personnel that are guarding the teams because they become soft targets when they are in the community. Secondly, there are a lot of security incidents with loss of life happening on an ongoing basis. But when it happens during a campaign, it gets news coverage in a different way. Most of the time, there is an inappropriate link made with the polio programme.
By and large, the vaccination teams across the country are well received. They remain engaged in the programme. Clearly, there are pockets of hostility, where the communities are hostile towards the programme but that’s where the dynamic is very carefully managed.
The district administration takes a very harsh view that communities can say no to vaccination but there is absolutely no right to be hostile or abusive towards vaccinators. It’s a priority of the programme to maintain positive relations with these communities. So in between campaigns, there’s a lot of outreach, engagement of community leaders to defuse this kind of hostility and tension.
But now and then, arguments break out at the doorsteps and the community and the vaccinators are trained to sort of step back, not to engage and supervisors are called to come and defuse the situation.
But this is not to take away from the courage and bravery of our front-line workers. Clearly, it’s hard work. Knocking at somebody’s door not knowing what you will encounter takes a lot of courage and confidence.
Al Jazeera: So what’s the outlook and what needs to happen for Pakistan to eradicate polio?
Jafari: The plan is to eradicate and stop transmission. Despite changes in government and security situations, these programmes have evolved, adapted and adjusted. And that’s why they have a level of population immunity that you’re not seeing outbreaks. They came very close in 2021 and 2022. And I think it is now a matter of getting to these final, hard-to-reach populations. And the programme is focusing on how best to reach these. It’s not a widespread problem across Pakistan. It’s not even a widespread geographic problem. It is now a combination of geographic and specific subpopulations that are harder to reach. When you start reaching these populations, progress happens very fast.
This interview has been edited for length and clarity.
