EFTA02678411.pdf

Grant Proposal Cover Page Date 4 September 2013 Project Title Polio Eradication and the Connection between Peace and Health Organization Name International Peace Institute (IPI) Project Duration (months) 60 months (2014-2018) Institutional official authorized to submit and accept grants on behalf of the organization: Prefix Ms. First Name Andrea Surname Pfanzelter Suffix Title Director, IPI Vienna Address Freyung 3 / 1010 Vienna / Austria Telephone Fax Email Web Site www.ipinst.org Project Director/Primary Contact: Prefix Ms. First Name Andrea Surname Pfanzelter Suffix Title Director, IPI Vienna Address Fre un 3 / 1010 Vienna / Austria Telephone Fax Email Web Site www.ipinst.org Total Cost Amount Requested of Project from Foundation in in Dollars Dollars (U.S.) $20,000,000 (U.S.) $20,001,375 Organization's revenue from last Organization's audited Financials Fiscal Year- in Dollars (U.S.) $9,151,315 End Date December 31, 2012 U.S. Tax Status (see Tax Status Definitions) 501(c)(3) Public Charity Geographic Location(s) of Project Field work: Pakistan, Nigeria, Somalia INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 1 EFTA_R1_01976466 EFTA02678411  IPI Offices: New York, Vienna, Manama IPI PROPOSAL: POLIO ERADICATION AND THE CONNECTION BETWEEN PEACE & HEALTH I. Proposal Overview: IPI's proposal to the Bill and Melinda Gates Foundation (BMFG) consists of two parts: an initial, model project aimed at reducing the security threats related to polio eradication in the few specific localities where it is still prevalent (Afghanistan, Pakistan, Nigeria, and Somalia); and a longer-term, overarching initiative on peace and health designed to reduce vulnerability and increase resilience related to the peace-and-health nexus by alleviating the disease and poor health that conributes to instability, and conversely, mitigating the sources of instability that threaten health. Polio Eradication A primary goal of the BMGF is to eradicate polio worldwide. Thanks to a highly successful global campaign over the past decade, polio has been successfully eradicated in 99.9 percent of the world. However, polio remains endemic in three locations: Afghanistan, Pakistan, and Nigeria. In fact, 100% of the polio cases in 2012 were found in 54 districts in these three countries. Recently, new cases have been identified in Somalia. Therefore, eradicating polio globally and permanently has come down to the last "golden millimeter"—reaching a few thousand children in a handful of isolated, unstable, inaccessible, and inhospitable communities. The areas in which polio is still a problem are geographically dispersed, but they share some significant characteristics: they are comparatively small and difficult to access due to insecurity, insurgency, or conflict; and the lack of state authority or control has enabled local power brokers to shape the discourse. In all of these regions, public health is being used as a tool in misinformation campaigns, whether intentionally or as a by-product of a broader political or ideological agenda, which has put the health of children at risk. Health workers are also at risk. Several health workers involved in the polio eradication campaign were recently killed in Nigeria and Pakistan. In August 2013 Medecins Sans Frontieres announced it is closing all its programs in Somalia after a 22-year presence due to attacks on its staff. IPI therefore proposes to assist the BMGF to better understand the local conditions, identify the drivers that (or who) can turn the situation around, and provide advice on what steps can be taken to improve the chances of eradicating polio in the remaining few localities where it is still present. IPI's work will involve, inter alia, providing situation assessments of the vulnerable communities, carrying out and/or analyzing quantitative surveys of the affected communities, facilitating access to these communities, and (based on the knowledge of the local conditions) assisting in the development of communications strategies to eradicate polio. The Connection betwenn Peace and Health 2 INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 EFTA_R1_01976467 EFTA02678412 IPI's work on polio eradication is the first step in a broader, long-term initiative on peace and health. As stated in the World Health Organization's Ottawa Charter for Health Promotion (1986), peace is a primary condition for health. Instability makes people and communities more vulnerable to disease, and prevents them from living healthy and productive lives. For example, polio is proving hardest to eradicate in regions of some of the world's most unstable countries: Afghanistan, Pakistan, Nigeria, and Somalia. Conversely, stability fosters an environment conducive to providing humanitarian and development assistance. Therefore, IPI is launching a peace and health initiative to better understand the links between peace and health, and to generate policy support to reduce vulnerability and increase resilience to health-related problems that contribute to instability, and conversely, to mitigate sources of instability that threaten health. The initiative aims to become a thought and policy leader on the connection between health and stability— understanding the links and their negative aspects, and promoting remedial solutions. This is vital since peace and health interact in many different ways. The most significant, and malign, link is the fact that people are killed, injured, disabled, abused, or traumatized due to armed conflict. Conflict prevention, mediation, and peacebuilding are therefore vital for saving lives. In addition, armed conflict has indirect effects on global health. These include: 1) impeding access of health professionals and humanitarian agencies to populations in need (conflict-affected countries have on average less than one health professional per 10,000 people); 2) "flight" of health professionals from conflict zones for safety issues (health workers are often targeted by government security forces as well) as we are currently witnessing in Syria and Somalia; 3) lack of supplies and basic equipment in hospitals and clinics in conflict zones, as well as difficult and unsafe access to health facilities for populations in need, also due to deterioration of infrastructure and transportation; 4) decrease in government expenditure on healthcare; 5) food shortages due to damaged agricultural structures, collapse of the economy, aid deliberately withheld, and disruption of the family unit; 6) three to four times higher under-5 child mortality rates in conflict zones than in the rest of the world; 7) sharp decline in basic childhood immunization in conflict zones; 8) highest rates of maternal deaths due to childbirth complications and other debilitating conditions in conflict-ridden or post-conflict states; 9) increased incidents of sexual violence towards women and children, with greater numbers of sexually transmitted diseases, as well physical and psychological trauma; and 10) increased incidence of infectious diseases (malaria, cholera, measles) during conflict due to malnutrition, unsanitary conditions, lack of clean water, etc. These factors create a vicious cycle. Greater instability endangers health, while greater vulnerability (including disease) breeds instability. Indeed, states characterized as fragile or failed (including those that have high rates of polio) tend to have far worse population health indicators than states at comparable levels of development. As of today, for example, no low-income fragile or conflict-affected country has yet achieved a single Millennium Development Goal (MDGs). Poor health indicators are a product of inadequate governance and service development. Moreover, fragile states tend to be affected by humanitarian crises that endure for years. In other words, a context of continuing crises and emergencies, combined with weak or non-existent local and national institutions, can undermine health improvements or nullify health investments and programs in the long-term. INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 3 EFTA_R1_01976468 EFTA02678413 While armed conflict and instability undermine health goals, the opposite is also true. Investments in health, conflict resolution, and statebuilding can be mutually reinforcing. Conflict resolution and peacebuilding measures can help prevent or lessen the impact of the above negative outcomes of armed conflict on public health. At the same time, the position of medical professionals in society, given their neutrality, credibility, and equality, can be a precious resource during negotiations, as are health-related cease-fires. The fact that health issues are of interest to all warring parties can contribute to this advantage. Moreover, health investment can contribute to statebuilding and legitimacy of institutions. In the long term, stronger healthcare systems can improve the health of the population, leading to greater productivity, stronger economies, less violence, and state stability. Evidence also indicates that improved health services can increase trust in state institutions, thus contributing to the authority and legitimacy of the government. In short, while poor health and instability have a negative impact on each other, peace and health are mutually beneficial. It is therefore necessary to promote peace as a primary condition for health, and to improve health as a way of promoting peace and development. That is the objective of IPI's work on peace and health. Since this is an ambitious objective that will require significant time, money, and knowledge, IPI intends to mobilize resources to develop proposals for how it could be possible to monitoring globally the nexus among peace, security, and health. The link between instability and disease is starkly illustrated by the situation in Syria and neighboring countries where contagious diseases like polio are threatening to become massive health problems amongst the internally displaced and the rapidly growing refugee population in Iraq, Jordan, Turkey and other neighbouring countries. IPI has recently convened several high-level meetings on the humanitarian crisis in Syria (see Annex). In its work on peace and health, IPI will also draw on its experience in conflict-ridden regions like West Africa. II. PROJECT DESCRIPTION: Polio Eradication 1. Context: The effort to eradicate polio globally and permanently has come down to the ability to ensure the effective treatment of children in just a handful of districts in the three countries where polio remains endemic. The remaining locations of polio cases are highly concentrated in a relatively small number of districts where the central government is unable to provide public security and public-health services. For example, 23% of all global polio cases in 2012 were reported in just three Local Government Areas of Nigeria: Katsina and Batsari in Katsina State and Minji bar in Kano State. In Pakistan, two regions of North and South Waziristan in Khyber Pakhtunkhwa (KPK) account for over 40% of Pakistan's polio cases. The vast majority of remaining cases are found in the Federally Administered Tribal Areas (FATA), where parents are 40% more likely to refuse treatment than in any other part of the country. Nigeria 4 INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 EFTA_R1_01976469 EFTA02678414 Nigeria has the highest rates of polio, with the north of the country the main source of polio infections. The country accounts for over half of global cases and is the only country with ongoing transmission of all three serotypes of the polio virus. Nigeria also has the highest rates of children missed in vaccination campaigns and the highest rate of parents refusing to vaccinate their children. Going back more than a decade, polio vaccination campaigns in Nigeria have suffered from targeted misinformation strategies and attacks by the terrorist group Boko Haram, weak social mobilization campaigns, and lack of commitment by some local leaders. Some strategies have also backfired. For example, the tactic of awarding higher salaries and bonuses to polio workers in order to encourage health workers to carry out vaccinations has not worked. Low-paid healthcare workers are offered extra cash for helping with the campaign, and as a result the primary healthcare system in Nigeria, which is very weak, is emptied out for days nearly every month. Additionally, it may not help that workers are paid according to how many children they reach, with it being reported some vaccinators refuse to accept cards showing children have already been vaccinated. The percentage of Nigeria's budget spent on social mobilization is less than 5%, significantly smaller than that spent on social mobilization in Pakistan. It is reported that even basic community efforts, such as polio posters and banners, are conspicuous in their absence. This is a point of concern as Nigeria has the highest non-compliance (refusal) rates of any country where polio persists. Refusal to take medicine stems from a fear of Westerners and Western medicine, as there is the perception in some communities the vaccination campaign is a Western plot to kill Muslim Africans or to make Muslim children sterile. Pakistan A new polio outbreak has occurred recently in North Waziristan, Pakistan, near the frontier with Afghanistan. It is in an area where a warlord banned polio vaccinations after it was disclosed that the C.I.A. had staged a hepatitis vaccination campaign in its hunt for Osama bin Laden. The warlord, Hafiz Gul Bahadur, has banned all efforts until American drone strikes end. This is a significant setback to the Pakistan campaign, which has persistently continued its efforts despite the killing of 9 vaccinators in December 2012, which has been attributed to the Taliban. Afghanistan Afghanistan's quest to eradicate polio is inextricably linked to that of neighboring Pakistan. Genetic analysis shows clear chains of transmission between the two countries. There are three chains of polio transmission in Afghanistan: two are from Pakistan, and the third is indigenous to Afghanistan, making the country endemic in its own right. Due to this closely intertwined relationship, future efforts to eradicate polio will likely require Pakistani and Afghani vaccination teams on either side of the border to coordinate strategy so that no child goes missing in between. As of now, vaccination coverage data suggest little improvement in the number of children reached with vaccination and there are indications that coverage levels in some districts are falling. Inaccessibility is a challenge in implementing vaccination campaigns; however, the main challenge anti- polio initiatives face in the country are basic leadership and management problems that are not properly addressed. In May 2012 it was reported that an Inter-Ministerial Task Force had been formed and would direct a whole-of-government approach to polio eradication. Five months later, this Task Force had yet to meet. At the same time, the President's launch of Afghanistan's Emergency Action Plan is welcome, but the slow pace of implementation is concerning. Additionally, District EPI Management Teams (DEMTs) need further strengthening and NGOs implementing the Basic Package of Health Services need to be held accountable for achieving higher coverage rates of routine immunisation, including polio. INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 5 EFTA_R1_01976470 EFTA02678415 Permanent Polio Teams in southern Afghanistan have long been credited as the program's flagship innovation. They have provided polio drops to 146,000 children, including almost 9,000 who had never previously received a dose of the vaccine. Key to their success is their low visibility and step-wise introduction. However, their geographic coverage is limited, and they are active in only five of the thirteen high-risk districts of southern Afghanistan. Somalia Somalia is highly prone to public-health crises, including outbreaks of cholera, typhoid, malaria, and measles. Recently the country has seen an outbreak of polio, which as of the end of July 2013 had paralyzed 105 children, where previously a case of polio had not been recorded in more than five years. Somalia is one of the countries in the "wild poliovirus importation belt"—a band of countries stretching from west Africa to central Africa and the Horn of Africa, which are recurrently re-infected with imported polio virus. Although the situation varies across Somalia, parts of the country have been torn apart by decades of conflict, chronic poverty, inequality, food insecurity, and public-health challenges. It was ranked 165th out of 170 in the 2012 Human Development Index in 2010, with 74% living on less than US$2 per day. Life expectancy across the country is a mere 50 years and the youth population of Somalia (14-29 years) is a disproportionately high 42% of the population. The country is highly prone to humanitarian emergencies, particularly drought and famine, due to very low rainfall, the on-going conflict, and increasing deforestation. It is likely that the greatest challenge in implementing the polio vaccination campaign will be security concerns, as foreign aid organisations are unable to access parts of the country still prone to conflict or under Al-Shabaab control. Somalia is navigating the most promising landscape for peace and stability that the country has seen in more than two decades, but Al-Shabaab remains a major spoiler to all peacebuilding and development initiatives in the country. Al-Shabaab has splintered following a "coup" which resulted in the killing of one of the group's co-founders, Ibrahim al-Afghani, an Al Quaeda—trained fighter who also fought in Afghanistan, and two further leaders have been forced to flee in recent months. The splintering of the group has triggered a wave of fresh violence as different factions fight for control of power and territory. The recent spate of violence in Mogadishu, the June car-bombing of the UN compound, and the shooting at a Swedish diplomat in August are all examples of the risk posed by the group. The constant threat has a very real impact on aid and development efforts in the country; for example, Medecins Sons Frontieres announced in August 2013 it is closing all its programs in the country after a 22-year presence due to attacks on staff. Common Themes The areas in which polio has been found may be geographically dispersed, but they share some significant common characteristics: they are comparatively small, difficult to access, and with little or no presence of the state that has allowed local power brokers to define the debate. These regions have been subject to longstanding misinformation campaigns, whether intentionally or a by-product of a broader political or ideological agenda, and this has resulted in the health of children being put at risk. Local governments have been unwilling or unable to provide for the public health of their citizens. Non-state actors (i.e. religious, tribal, or community leaders, as well as armed groups) are filling this vacuum in a malign way, including by misinforming communities on the dangers of polio and the benefit of vaccination campaigns. In turn, in all of the regions families are seen avoiding or refusing to have their children vaccinated for polio. 6 INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 EFTA_R1_01976471 EFTA02678416 Additionally, polio workers have been the targets of violence in these areas. In some cases, suspicion and misinformation are causing aggression, violence, and murder against those delivering vaccines. Other drivers of the violence stem from groups that profit (politically) from the instability created by going after "soft" targets, i.e. health workers. While polio is limited to these select regions, their environments are not unique, which highlights vulnerabilities that might be exploited in other regions, e.g. the Sahel, by groups benefitting from instability and insecurity. 2. Rationale Specific Need: For future polio vaccination initiatives to be successful in these regions, it is necessary to find entry points that will find support among the affected communities. While short-term intervention strategies might provide the surge required to impact the polio eradication campaign, in the long-term there needs to be a change in the perceptions that are triggering the resistance to the campaign. As such, it is essential to identify entry points that will change social paradigms, breaking down misperceptions and misinformation and circumventing security risks. Why this project is an effective means to address this need: In order to move forward, a nuanced understanding of the perceptions and sources of long-term miscommunications that have led to families' failure to protect their children from polio is essential in identifying project entry points. A number of initiatives have been undertaken in the affected regions, but with limited success, and sometimes unforeseen results—as demonstrated by the award of bonuses to healthcare workers in Nigeria. Lessons learned from eradicating polio in other countries have demonstrated that a pre-requisite to a successful campaign is public information, communications, and community-level advocacy. This is also true in the remaining communities, but the messaging and delivery need to be adapted and customized to the prevailing misconceptions and the sources of those misperceptions in those specific communities. To be successful, it is essential to have a nuanced understanding of the local conditions, as well as the attitudes, perceptions, and experiences of the affected population. Intervention at state level and with central government ministries or authorities is necessary but not sufficient to reach these communities and to change their views towards polio eradication. In encouraging a positive response to anti-polio campaigns, it is essential to understand why people are reacting negatively to the anti-polio campaign, and to take steps to get them to support it and participate in it. In the process, it is essential to de-link the polio issues from all others, and thereby "depoliticize" it. Thus, a bottom-up approach is required. Without a better understanding of what the people in these communities believe about polio and an analysis of social and political dynamics in the target communities, it will be impossible to have impact. By understanding the perceptions, it should be possible to change perceptions, creating an environment more conducive to the successful implementation of the polio eradication campaign. INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 7 EFTA_R1_01976472 EFTA02678417  Oth . ‘;, • 1t€2 4 Conflict, Long-term, Fear, mistrust, insecurity, localised misjudgment absence of state misinformation Geographic locations & the direct beneficiaries: Geographic locations will be limited to very specific ones in Somalia, Pakistan, Afghanistan, and Nigeria, identified through the situation assessments. It should be noted that within these countries, the danger of polio transmission exists not only in remote areas with inadequate health facilities but also in urban slums and "catchment" areas. Direct beneficiaries will be mostly those children who are, for various reasons, currently excluded from cycles of polio-eradication programs: as a result of conflict and /or security issues which block access of health teams to the children; use of religion-based bans on anti-polio vaccines as part of larger security and development issues; remote areas which are difficult to access; under- or misreporting of immunization coverage; and corruption issues which affect parts of the chain which makes up the direct and correct delivery of anti-polio vaccines. Secondary beneficiaries would be all members of the affected communities who would benefit by greater stability, development, and better health. List of key partner organizations, sub-contractors, and sub-grantees that are critical to this project's successful implementation; description of the history and current status of these relationships: Pamela? Allison? Camilla? (TO BE COMPLETED) WHO, UNICEF, ICRC, relevant NGOs, civil society. IPI will also draw upon its extensive network of contacts within multilateral organizations (particularly the UN family), regional organizations, senior officials at various levels of government, specialized health agencies, experts, and representatives of civil society. The Connection between Peace and Health Areas of focus for IPI's work on peace and health will include: • Health: how can peace contribute to health, and health to peace? 8 INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 EFTA_R1_01976473 EFTA02678418  • Humanitarian issues: what steps be taken to improve disaster risk reduction? What can be done to improve the humanitarian response to displacement and famine, particularly in relation to health? • Food and water security: how can vulnerability to food and water insecurity be reduced for the more than 1billion people who are starving and/or lack access to clean water? • Development: how can development increase resilience to ill-health, and what steps can be taken to create a virtuous cycle between improved healthcare and increased development, particularly in the post 2015 Development Agenda? • Conflict prevention: how can conflict prevention, mediation, and peacebuilding reduce the impact of conflict on health and development, particularly in fragile states? • Transnational threats: what can be done to reduce the threat posed by organized crime to health—for example, in relation to counterfeit medicines, and crime-related violence? • Sustainable urbanization: what steps can be taken to improve the chances of implementing the Millennium Development Goals in cities, and what lessons can be learned from safer, rather than failing, cities? This work will map global trends and compile information on areas of vulnerability, drawing on IPI's strategic assessments, its Global Observatory, and mapping skills. It will also look at how technology can be used to reduce threats and enhance resilience. For each issue area, IPI will look at best practices and successful case studies in order to identify factors that promote resilience. The aim is to carry out evidence-based research and assist policy-makers in order to have an impact on policy. Working with a wide range of experts from the private sector, academic institutions, think tanks, civil society, specialized institutions, inter-governmental organizations, and all levels of government, IPI will develop a series of operational recommendations on how to strengthen resilience in the areas of focus. In the process, it will help strengthen networks among actors from a cross-section of backgrounds. These connections can enable more effective prevention, and a quicker response during times of crisis. III. ALIGNMENT WITH STRATEGY: Aligns to BMGF goal to eradicate polio as part of Global Development Program: The BMGF has a proven track record of promoting strategies that aid in the fight to eradicate polio. The IPI project aligns to these strategies most closely in the areas of the polio vaccination campaigns and legacy planning. The project has the potential to be a pivotal tool in achieving the BMGF priority of improving the quality of campaigns in Nigeria, Afghanistan, Pakistan, and Somalia, as well as other areas of Africa that are at risk of polio importation. Specifically, it can improve the BMGF's understanding of local social, cultural, political, and religious barriers to improving vaccination coverage, and identifying entry points to overcome these obstacles, engaging local stakeholders and communities. Also, IPI supports the sanctuary model, emphasizing quality over quantity in vaccination campaigns. This is also important in order to avoid vaccination fatigue. Some children are immunized again and again, until the families cease to believe it does any good—and then they start refusing. The small number of polio cases requires mapping exercises and immunization campaigns to pinpoint which children are not being INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 9 EFTA_R1_01976474 EFTA02678419 vaccinated (and why), and adopting implementation strategies that are tailor-made to the specific local conditions. While polio eradication is the focus of this project, like the BMFG IPI is looking to the future and the impact that polio vaccination campaigns can have on future healthcare initiatives. Therefore, IPI will make an indepth study (particularly of fragile states)to better understand the links between peace and health, and to generate policy support to reduce vulnerability and increase resilience to health-related problems that negatively impact stability, and to mitigate sources of instability that negatively impact health. The project will build on both the BMGF and IPI's already substantial capabilities, developing a wide range of assets, including detailed knowledge of high-risk groups and vulnerable regions, effective planning and monitoring procedures, and highly trained technical staff, as well as local and regional technical advisory bodies. Furthermore, in line with the BMFG's strategy that taking risks and making non-traditional investments can lead to valuable program improvements, the project works by the philosophy that risky investments are sometimes essential to ensure that hard-won healthcare gains can be capitalized upon and sustained. Yet over the long-term, such investments can reduce risk. How this Project fits into events & developments in the field and/or relevant geographic area to address the identified need: In the case of Somalia, this project presents an unprecedented opportunity to collect data on and address the challenges posed to polio vaccination campaigns, as well as healthcare in general, as a consequence of insecurity and quickly evolving community conditions. In Somalia, the attitudes towards polio vaccination initiatives are the newest and freshest, representing the opportunity to study how community perceptions regarding polio are developed and how they can be shaped to support vaccination campaigns. It also allows for changing these misperceptions and reversing the trend before it becomes too entrenched. As such, it is imperative to act quickly. By getting in on the ground at an early stage and implementing a project driven by data and in-depth community insight, there is a better chance of stemming the tide of negative propaganda and advance the anti-polio campaign. Insights gained in Somalia may also be transferable to countries such as Pakistan, Afghanistan, and Nigeria that are part of the existing campaign. It may also allow a shift towards a preventive approach in countries where similar conditions of underdevelopment, poor reach of government service delivery, and growing international terrorist movements may pose a further threat to the global polio eradication campaign. In particular, the Sahel countries of Mali, Niger, Mauritania, and Burkina Faso may become vulnerable to similar campaigns, as the influence of Al-Quaeda in the Islamic Maghreb (AQIM), which shares institutional links with Boko Haram and Al-Shabaab, is growing in the region. As a result of massive international and national efforts and funding, Pakistan was on the verge of complete polio eradication. However, a number of factors conspired to complicate the situation and increase resistance to the eradication campaign. These included external circumstances like political- military instability, terrorism, drone attacks and resulting anti-US sentiment, a Taliban-imposed ban on the polio-eradication program, and the May 2013 elections which led to changes in government and staff. There were also internal factors, including religion-based and traditional factors, as well as corruption, poor infrastructure, mis- or under-reporting, and rivalries and jealousies over how polio- related funds were to be allocated. 10 INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4,2013 EFTA_R1_01976475 EFTA02678420 In the case of Afghanistan, the Project will initially focus on the Pakistan-Afghanistan transmission and re- transmission aspects, with countless children moving regularly via unofficial crossings, thus missing out on scheduled anti-polio immunization on both sides. The project will also consider how the withdrawal of ISAF/NATO troops could impact polio eradication. IV. IMPLEMENTATION & RESULTS: Description of how IPI will achieve the Outcomes & Milestones, including Coordination and Sequencing: To carry out the polio-eradication project, a project plan will be employed consisting of four phases: • Situation assessment: IPI will conduct a situation assessment determining the local conditions, particularly those that make the affected communities vulnerable. Who are the powerbrokers and what are their incentives to either support or block the polio-eradication campaign? What are the risks involved? • Survey: Survey work is an instrumental component in overcoming cultural barriers. Where existing information is insufficient, quantitative surveys of representative samples in target communities will be conducted to build community understanding, providing a greater and more in-depth knowledge of what communities believe about polio and an analysis of social and political dynamics. Questions that may be asked include: what do respondents know about polio, its transmission, its stages, it effects and the campaign to respond? Have respondents been offered the vaccine? How did they respond? Are they aware of the polio campaign? Who gives them their information about polio? What aspects of it have they witnessed and how did this affect their knowledge and understanding? Who takes the decisions in the households regarding healthcare and child-rearing? Would respondents give the vaccine to their children? What would encourage them to do so? How does polio rank against other health concerns? Would they choose to vaccinate their children? Women will be the greater focus of this study as it is expected that mothers will be those prepared to resist prevailing cultural norms to protect the health of their children. Due to the sensitivity of the topic, questions will be couched within a broader context of public-health issues, such as maternal and child health, nutrition, and well- being. • Facilitation: On the basis of the information provided by the situation assessment and survey, we will determine the drivers (particularly key individuals) and entry points for changing perceptions and attitudes. As required, IPI will also mobilize high-level contacts between the Foundation and relevant government, multilateral, and business leaders. • Communications strategy: IPI will work with the BMFG and key players in affected communities to develop an advocacy campaign that can "turn" opinion in favor of anti-polio vaccinations. The campaign will be designed to promote social mobilization in a comprehensive and sustained way to break down longstanding misperceptions and misinformation, to highlight the risks of polio, and to encourage parents to bring their children forward for vaccination. At this time recommendations for enabling implementation of the anti-polio campaign in the affected communities, through existing delivery mechanisms, will also be made. INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 11 EFTA_R1_01976476 EFTA02678421 We believe that these objectives are reachable under the current, albeit difficult, prevailing conditions. However, the timelines and "deliverables" would have to be reviewed if there were major negative changes in the external environment. IPI's work on peace and health will focus on the following outcomes: • An annual high-level meeting on peace and health; • Supporting centers of excellence and international networks on disaster risk reduction to better prepare for and respond to mega-disasters; • Carrying out projects to improve food and water security, and to enhance policy in relation to the food-water-energy nexus; • Supporting projects designed to create a virtuous cycle between improved healthcare and sustainable development, particularly as part of the post-2015 Development Agenda; • Implementing a project on reducing vulnerability and strengthening resilience in cities in order to promote sustainable urbanization and to prevent the rise of "failing cities"; • Mainstreaming the issue of health into IPI's core activities devoted to conflict prevention, mediation, and peacebuilding, particularly in fragile states; • Introducing a health perspective into IPI's work on transnational organized crime in order to reduce death and injury from crime-related violence, and to improve policies designed to tackle counterfeit medicines. Implementation Timelines and Phasing The polio eradication project will take a phased approach in each of the four countries, following the steps of situation assessment, survey, facilitation, and communications strategy, with lessons learned from one country to be shared with others. A detailed overview of Outcomes and Milestones is provided in Appendix A. IPI will collect the lessons learned from the polio-eradication project, and build on these to look at other situations where there is a nexus of peace and health. Over a period of five years, IPI will launch a series of projects that relate to the peace-health nexus , including: natural disasters (and humanitarian affairs); development; sustainable urbanization; food and water security; conflict prevention; and organized crime. The re-emergence of polio in conflict-prone regions underlines the need to address polio as part of a wider and holistic set of interventions that looks at peace and health. Focusing on polio alone will not address the underlying conditions of vulnerability. It may also divert resources and attention from other problems and health issues, risking a backlash against the polio campaign and workers. Therefore — as the examples of Pakistan, Nigeria and Somalia illustrate — it is impossible to eradicate poverty without addressing the underlying, broader issues of which security, peace and stability are essential. 12 INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 EFTA_R1_01976477 EFTA02678422 Any External Factors or Significant Challenges that would hinder implementation of the Project and proposed Steps to address or mitigate them: See section VII on Risks. V. ORGANIZATIONAL CAPACITY: Description of IPI's strengths & capacities to implement, manage & monitor progress, including: IPI Mission Statement The International Peace Institute (IPI) is an independent, international not-for-profit think tank with offices in New York, across from United Nations headquarters, in Vienna, and a Middle East regional office in Manama, Bahrain. IPI is dedicated to promoting the prevention and settlement of conflict by strengthening multilateral institutions. It sees peace and security as prerequisites for poverty eradication and development. To achieve its purpose, IPI employs a mix of policy research, strategic analysis, publishing, and convening. The Institute was founded in 1970 as the International Peace Academy (IPA), which focused on training military officers and diplomats for United Nations peacekeeping operations. In 2008, the organization changed its name to the International Peace Institute to reflect its current identity as a research institution that works with and supports multilateral institutions, governments, civil society, and the private sector on a range of regional and global security challenges. IPI also carries out work in and on Africa, the Middle East, Europe, and Central Asia. With a staff from more than twenty countries and a broad range of academic fields, IPI partners with regional organizations, think tanks, universities, and NGOs to conduct research, produce publications, and convene meetings in many parts of the world. ■ Missions/goals and current activities related to the Project: "Polio Eradication and the Peace and Health Initiative" would in many ways be an extension of other IPI projects, allowing IPI to introduce the health perspective into its work and analyze new links. For example, IPI has an established track record of work on conflict prevention, mediation, and peacebuilding, but IPI will now explore how these tools can be used to reduce the impact of conflict on health and development, particularly in fragile states. Similarly, IPI will be able to enhance its work on humanitarian issues and transnational threats, respectively, by looking at their relationship to the health aspect, as well. ■ How the Project furthers the specific mission/goals of IPI: A new workstream focused on peace and health, starting with polio eradication specifically, will be an essential new piece in IPI's work to promote the prevention and settlement of conflict and to reduce risk and vulnerability. IPI will carry out analysis on the link between peace and health, and present its research findings, with recommendations, to policymakers. This will position IPI to expand its work to build the capacity of international institutions —a core component of IPI's mission—to address peace and health issues also. ■ Description of IPI's leadership, management & operational structure: IPI is governed by a board of directors who convene biannually to address organizational issues and to review and approve IPI's annual budget. IPI's President sits on the board of directors and heads IPI's INTERNATIONAL PEACE INSTITUTE SEPTEMBER 4, 2013 13 EFTA_R1_01976478 EFTA02678423  management team, who collaboratively oversee IPI's three offices. In addition, two non- governing Advisory Boards provide input to IPI's New York and Vienna offices, respectively, as needed. ■ Similar types of projects IPI has undertaken in the past. including the goals of those projects and success in relation to those goals: Since 2006, IPI's flagship research program, Coping with Crisis, Conflict, and Change (CWC), has provided policymakers with analyses of conflict management tools and transnational threats to peace and security and offered a platform for decision makers to build consensus on ways to strengthen multilateral response capacity. CWC will serve as a model for the work IPI will conduct on peace and health, which will involve exploring new linkages and trends and putting forth recommendations for international institutions to address them. In recent years IPI's Middle East Program has carried out numerous survey projects with similarities to the one proposed on polio eradication. Through these projects, IPI gained experience with field-based, in-person polling, as well as phone banks. The surveys aimed to develop portraits of key groups, issues, and motivators in the region in order to better understand the current situation and produce up-to-date and relevant policy research. The polls received wide, international media coverage. Using the polling data, plus fresh analysis on the issues, IPI developed visual presentations to describe trends and challenges in the region. IPI's polling results and related presentations have been given at its ministerial dinners and to constituents in New York, Washington, DC, and in European and Asian capitals. (add section on Syria and refer to annex) Additionally, as part of its Arab Youth Project, IPI conducted interviews in Egypt in 2012 to develop an understanding of the shifting aspirations and activism of the youth. Through the publication of the project's findings and related convening, IPI is providing policymakers with an insight into the youth's priorities and their role as influencers within the Arab world's new political landscape. IPI's Peace without Crime project has developed a methodology for analyzing organized crime in fragile states and IPI staff members have experience as a result of this, and other projects, with operating in difficult environments. ■ Unique characteristics/activities of IPI that make it particularly well-suited to implement this Project: IPI's niche lies in its ability to generate cutting-edge research, policy analysis and recommendations, and to reach and influence policymakers at all levels. These qualities would be fully leveraged for the benefit of the project. IPI's work is disseminated through the organization of more than 100