Pakistan has a high infant mortality rate, which is linked to low levels of immunisation. There is an urgent need for coordination among institutes for reducing demand and supply gaps in enhancing immunisation coverage nationally write Ghamz E Ali Siyal and Shahbaz Tufail.
From the perspective of public health investment, immunisation programmes are considered the most successful and cost-effective for saving future generations. Globally, around 6 million children died in 2015 and out of that 30 percent resided in South Asia. Eight million out of 23 million under-immunised children resided particularly in Pakistan, India and Afghanistan.
Pakistan is considered to be fastest growing country in South Asia with a growth rate of 2.4 percent. However, infant and maternal mortality rates are very high. Almost half of population face issues related to malnutrition, particularly children under the age of five. The lower rate of immunisation and higher prevalence of deaths have also contributed significantly in number of deaths in Pakistan. With lower immunisation rates, 53.8 percent in 2012-13, the future generations of Pakistan are at a risk. While it is easy to target the blame on the government, various reasons at the provincial level affect the demand and supply aspects.
Pakistan ranks 29th in the World Infant Mortality Rate (IMR) and 8th in Asia, i.e. 52.10 per 1,000 births. The higher rate of child mortality can be expected from lower rates of immunisation. As per Pakistan Demographic Household Survey (2012-13), national coverage rate of child vaccination is 53.8 percent (GoP, 2017). Stunting is common in as high as 44 per cent of children and 31.5 per cent of children are underweight. In terms of rural–urban division, stunting among children and underweight issues are higher in rural areas as compared to urban areas. Almost, 35,000 children die of diarrhoea yearly before age of five. Last year, threats from chickenpox were still looming as 16 children died from it.
The lower rates of immunisation are a significant issue in Sindh and Balochistan. Provincially, Punjab is leading Khyber Pakthunkuwa (KP), Sindh and Balochistan. Immunisation coverage in Punjab and KP has significantly improved because of active role of local governments in the past decade. Immunisation coverage stands at 65.6 percent in Punjab and 52.7 percent in KP. The accountability factor of government functionaries at supply side and awareness among families regarding the benefits of immunisation are possible factors behind these such good rates. However, immunisation rate in Sindh is 29 per cent and Balochistan is 16.4 per cent .
The government of Pakistan is providing free vaccines to save children from preventable diseases under Expanded Programme on Immunisation (EPI), launched in 1978 for improving immunisation against preventible diseases. It targets to immunise 6 million children of age group between 0 to 11 months. This immunisation process is based on vaccinations for coping nine diseases: childhood tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type b, pneumonia, and measles. Apart from vaccinations for children, vaccinations are also provided to pregnant women against tetanus. The devolution of ministries has increased role of provincial government in implementation of programmes. The differences in immunisation coverage rate provincially validate differences of service delivery of this programme.
There are various factors which came on forefront during a project conducted by Sustainable Development Policy Institute (SDPI) and Global Alliance for Vaccination and Immunisation (GAVI). This project focused on less immunised provinces, namely, Sindh and Balochistan. This included involvement of key stakeholders such as civil society organisations, media, local government representatives and parliamentarians during advocacy sessions.
In Sindh province, major barriers in routine immunisation are lack of awareness about immunisation and its outcomes, lack of access to vaccination centres, inadequate financial resources, poor performance of local governments, and inefficient service especially in urban slums as well as rural and remote areas. Besides, low income, low levels of literacy and less understanding of social mobilisers about the issue also contributes to lower immunisation. Additionally, lack of coordination among federal, provincial and local governments and weaker role of social and electronic media are also potential barriers. Few stakeholders identified negative perception about vaccination hinder immunisation.
In Balochistan, major barriers to immunisation are lack of awareness about vaccination process, lack of health services, lack of planning and commitment of staff, shortage and negligence of field workers. Instead of security issues, cultural and religious barriers also negatively affect immunisation coverage. Door-to-door vaccination is not possible because of scattered and complex geographic structure of the province. Lack of interest of print and electronic media in creating awareness about routine immunisation and lack of accountability and governance in addressing health programmes, and inefficient role of EPI staff led to minimum immunisation coverage. Furthermore, lack of legislation on routine immunisation a major barrier in tackling the issue in Balochistan.
The EPI representatives from Sindh and Balochistan described lack of funds was a major barrier in achieving possible outcomes. The budget allocation by PSDP for EPI is about Rs 2792.693 million and assistance by GAVI was Rs 477 million. The EPI staff has increased its outreach and improved services provisions in all provinces. They are hopeful to have achieved 80 percent of immunisation coverage nationally.
These problems highlight need for coordination among institutes for reducing demand and supply gaps in enhancing immunisation coverage nationally. The major suggestions for improving immunisation given by stakeholders are to conduct baseline studies for identifying vulnerable areas in each district. The awareness campaigns are needed by engaging clerics, print, electronic and social media, and government organisations especially in remote areas. The formulation of act or bill to make immunisation mandatory is a key to improve immunisation both provinces.
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About The Authors
Ghamz E Ali Siyal, Research Assistant, Sustainable Development Policy Institute (SDPI), Islamabad.
Shahbaz Tufail, Advocacy Assistant, Sustainable Development Policy Institute (SDPI), Islamabad.