This article was written by Hira Farooq, a student in Gavin Yamey’s master’s course, “Global Health Policy: Transforming Evidence Into Policy.” In the piece, she uses John Kingdon’s well-known multiple streams policy framework to understand how and why Pakistan prioritized polio elimination. The framework proposes that a policy concern rises to the top of a national agenda when three “streams” collide: the problem stream (identification and definition of the problem), the policy stream (development of policy solutions), and the politics stream (the political climate). Kingdon also noted the importance of policy windows (moments in time when the streams converge) and policy entrepreneurs (individuals skilled at bringing the streams together).
Since the establishment of its national Polio Eradication Programme in 1994, Pakistan has conducted hundreds of polio campaigns, declared polio elimination a top priority and a national emergency, and developed strategies approved by the Prime Minister and President.1 This article analyzes the prioritization of polio in Pakistan using Kingdon’s model.
Problem Stream
Polio has been a global priority since 1988, when the World Health Assembly passed a resolution on elimination and formed the Global Polio Eradication Initiative (GPEI). In 2020, wild poliovirus remained endemic in only Pakistan and Afghanistan.2
The annual number of polio cases in Pakistan fell sharply from 1155 in 1997 to 28 in 2005.3 Yet, cases then rose, particularly after the COVID-19 pandemic and the 2022 floods. Pakistan reported 74 cases in 2024, with the virus spreading to 90 districts, including previously cleared districts of Karachi, Quetta, and Peshawar.4
Misinformation around polio vaccination by militant extremists in tribal areas disrupted elimination efforts. Militants perceived vaccination as a Western agenda against Islam – they attacked vaccination teams and spread the rumor that the vaccine contained haram (prohibited) ingredients and caused infertility. This misinformation has led to increased government focus on, and even the military’s involvement in, polio elimination.5
Policy Stream
Pakistan uses nationwide door-to-door campaigns supplementing the routine polio immunization schedule with additional oral vaccine drops for every child under five.6 This approach reduced global polio cases by 99% and cases in Pakistan by 97% in the first decade after the launch of its Polio Eradication Programme, from 1994 to 2004.7
Donors and global partners, including the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Rotary International, the Gates Foundation, and Gavi, the Vaccine Alliance, provide strong financial and technical support to Pakistan’s polio infrastructure. Between
2016 and 2020, the GPEI spent US$1.16 billion in Pakistan.8 The WHO has supported elimination strategies, including the “2-4-6 roadmap 2024-25” (the goal of conducting two national, four sub-national, and six case-response campaigns annually), and has established 934 surveillance sites in Pakistan.9 Rotary has provided 200,000 vaccine transport units, established 23 immunization sites, and committed $150 million when Pakistan’s cases spiked in 2022.10 Thus, Pakistan has the strategy, funding, and infrastructure needed to combat polio.
Politics Stream
The global focus on polio places Pakistan’s program under scrutiny, creating pressure and accountability to strengthen polio elimination efforts. In 2014, the WHO declared polio a Public Health Emergency of International Concern, and reaffirmed this declaration in 2025.11 In 2014, GPEI’s Independent Monitoring Board declared polio in Pakistan “a disaster.”12 Senior officials, such as Polio Oversight Board Chair Dr. Chris Elias and Gates Foundation Chairman Bill Gates, often meet high-level stakeholders in Pakistan, including the Prime Minister.13
Global transmission of polio virus originating in Pakistan has raised concerns across many countries. For instance, China expressed concern when a case of polio was reported that originated in Pakistan. Virus strains originating in Pakistan were also detected in Egypt, Syria, the West Bank and Gaza, and Australia. Under WHO guidelines, travelers to and from Pakistan must be vaccinated against polio. Several countries require proof of polio vaccination for visa applications.14 Risk of reputational damage adds to political pressure on Pakistan to intensify polio elimination efforts.
With every political transition and general election in Pakistan, polio cases tend to rise as establishing a caretaker government and rapid bureaucratic transfers break momentum in elimination efforts.15 Yet, the new government will reaffirm its commitment to polio and show substantial engagement. For instance, the Prime Minister chairs meetings of the National Task Force on Polio Eradication, with operational follow-through by federal and provincial health ministers, chief secretaries, and district commissioners.16
Policy Window and Policy Entrepreneurs
Although the burden of disability-adjusted life years and deaths from polio in Pakistan is relatively small, given the small number of cases reported, being one of the only two polio-endemic countries makes the infection a notable problem.17 There is also a feasible and acceptable way to eliminate polio, with financial and technical support, that has worked worldwide – supplementary immunization campaigns. And international pressure translated into national political will. Thus, the convergence of the three streams opened a policy window, making polio a national priority. As cases still emerge, solutions are still in place, and international pressure endures, the window persists, and polio continues to remain high on the national agenda.
Policy entrepreneurs, mainly international donors and partners, continue to use this window to push for policy implementation. For instance, GPEI continues to develop new strategies, with the Polio Eradication Strategy 2022–2026 being the latest.18 WHO supported a two-month reset of the
program in 2024 to reevaluate all areas of work and plan collaboratively.19 Such a push makes the government course-correct and refocus.
Conclusion
Polio has been high on Pakistan’s health agenda with its global prioritization, which has shaped its perception as a problem, and generated sustained pressure and resources for government action.
1 Federal Directorate of Immunization, Pakistan. “Polio.” Accessed February 8, 2026. https://www.epi.gov.pk/vaccine-preventable-diseases/polio/.
2 Geddes, Linda. “The Endgame: What Will It Take to Eradicate Polio?” Gavi, the Vaccine Alliance, October 24, 2022. https://www.gavi.org/vaccineswork/endgame-what-will-it-take-eradicate-polio.
3 Nishtar, Sania. “Pakistan, Politics and Polio.” Bulletin of the World Health Organization 88, no. 2 (2009): 159–60. https://doi.org/10.2471/BLT.09.066480.
4 WHO Pakistan Polio Eradication Initiative Report. World Health Organization, 2024. https://www.emro.who.int/images/stories/pakistan/Polio-report-2024.pdf.
5 Rahim, Shabina, Zubair Ahmad, and Jamshid Abdul-Ghafar. “The Polio Vaccination Story of Pakistan.” Vaccine 40, no. 3 (2022): 397–402. https://doi.org/10.1016/j.vaccine.2021.11.095.
6 Nishtar, Sania. “Pakistan, Politics and Polio.”
7 Perveen, Dr Shazia. “Regression in Polio Eradication in Pakistan: A National Tragedy.” JPMA. The Journal of the Pakistan Medical Association, January 1, 2016. https://www.academia.edu/93379467/Regression_in_polio_eradication_in_Pakistan_A_national_tragedy.
8 Rahim, Shabina, et al. “The Polio Vaccination Story of Pakistan.”
9 WHO Pakistan Polio Eradication Initiative Report
10 Rajput, Rahul. “Pakistan Is Working with Rotary to Eradicate Polio.” Gavi, the Vaccine Alliance, October 31, 2022. https://www.gavi.org/vaccineswork/pakistan-working-rotary-eradicate-polio.
11 World Health Organization. “Statement of the Forty-Third Meeting of the Polio IHR Emergency Committee.” November 11, 2025. https://www.who.int/news/item/11-11-2025-statement-of-the-forty-third-meeting-of-the-polio-ihr-emergency-committee.
12 Baloch, Shah Meer. “Pakistan and the Politics of Polio.” The Diplomat, June 27, 2019. https://thediplomat.com/2019/06/pakistan-and-the-politics-of-polio/.
13 Press Information Department, Pakistan. “High-Level Polio Oversight Board Delegation Meets Federal Minister for Health Syed Mustafa Kamal.” March 7, 2025. https://pid.gov.pk/site/press_detail/29569; Arab News. “Pakistan PM Meets Bill Gates, Calls Partnership Key in Polio Fight.” September 25, 2025. https://www.arabnews.com/node/2616660/amp.
14 Mushtaq, Asim, et al. “Polio in Pakistan: Social Constraints and Travel Implications.” Travel Medicine and Infectious Disease 13, no. 5 (2015): 360–66. https://doi.org/10.1016/j.tmaid.2015.06.004.
15 Baloch, Shah Meer. “Pakistan and the Politics of Polio.”
16 WHO Eastern Mediterranean Region. “Polio Eradication within Reach in Pakistan.” December 13, 2021. https://www.emro.who.int/polio-eradication/news/polio-eradication-within-reach-in-pakistan.html.
17 World Health Organization. “Pakistan Health Data.” Accessed February 8, 2026. https://data.who.int/countries/586.
18 Geddes, Linda. “The Endgame: What Will It Take to Eradicate Polio?”
19 WHO Pakistan Polio Eradication Initiative Report.