Analysis of Pakistan's Immunization Program: Systemic Interactions and Implications

Author: Beenish Mehboob, June 14 2024 - Exploring the perspectives of immunisation programme staff, considering the interactive dynamics of system components within the broader ecological context, illuminates both barriers and facilitators to programme implementation. In Pakistan, where only two-thirds of children receive full immunisation, understanding these dynamics is crucial for addressing the chronic challenges faced by the country's immunisation efforts. Initiated in 1978, Pakistan's Expanded Programme on Immunisation (EPI) gained further urgency with the establishment of a high-level Emergency Operations Centre (EOC) in 2014, following the declaration of polio as a national emergency.

This study examines the views of policymakers, managers, and staff across different levels, aiming to dissect the building blocks of Pakistan's immunisation delivery system. It explores their interactions within the larger health system and the external social ecology, documenting the resultant challenges and opportunities. The analysis is framed by the World Health Organization (WHO)'s six building blocks: service delivery, health workforce, health information system, access to essential medicines, financing, and governance and leadership. This framework, though critiqued for oversimplification, serves as a foundational lens to understand the complex and dynamic interplay of factors within and outside the immunisation system.

A qualitative case study was conducted through semi-structured, in-depth interviews with 34 purposively selected key informants involved in immunisation policy and programme implementation. Key challenges identified include:

Service Delivery: Participants highlighted the ambiguity surrounding the optimal mode of vaccination delivery - whether through fixed centres or mobile teams. This debate is influenced by historical door-to-door polio campaigns and broader governance decisions, which have shaped public expectations. Additionally, EPI struggles to effectively reach mobile, marginalised, and hard-to-reach populations, compounded by inaccurate population estimates.

Health Workforce: There is a notable shortage of human resources, especially female vaccinators. The lack of succession planning and frequent managerial transfers result in loss of institutional memory and limited knowledge transfer, hampering programme effectiveness.

Health Information System: The credibility and accountability of data are areas needing significant improvement. The absence of accurate population data leads to flawed planning and reporting, with resources often being misappropriated. A comprehensive micro-census is suggested to establish an accurate denominator for vaccination targets.

Essential Medicines (Vaccines and Supplies): Accurate recording and reporting of vaccine availability, storage, utilisation, and wastage remain critical concerns. Instances were cited where vaccines were recorded as used but were not administered, indicating systemic inefficiencies.

Health Financing: A dedicated budget line for EPI is lacking, complicating financial planning and resource allocation.

Governance and Leadership: Coordination issues arise from the bifurcation of routine immunisation (RI) and polio eradication efforts within the same programme. Strengthening national ministry roles and enhancing inter-provincial coordination are essential to address these governance challenges.

Global Environment: Global factors, particularly the emphasis on polio eradication and the geopolitical context post-9/11, significantly impact the immunisation efforts. The prioritisation of polio has sometimes overshadowed the broader RI, which is fundamental for sustainable eradication.

National Policy: Health policy has traditionally focused on curative care rather than preventive measures. Discussions highlighted the need to engage the private sector, which currently contributes minimally to immunisation efforts.

Security Situation: The geopolitical instability and security challenges necessitate additional measures for the protection of immunisation workers, impacting programme implementation.

Community Perceptions and Practices: Demand-side issues, such as community misperceptions and vaccine hesitancy, are significant barriers. Tailored communication strategies addressing local misperceptions and integrating with broader public health messages are required to improve community engagement.

The study underscores that many gaps emerge at the intersections of EPI with the broader health and governance systems. Addressing these requires coordinated efforts across the entire system, including policy decisions on private sector regulation, security negotiations, and priority setting in the face of global health initiatives. Fully integrating EPI within the broader health system is posited as a critical step towards enhancing immunisation outcomes.

In conclusion, the synergistic engagement of local, national, and global stakeholders is essential for improving Pakistan's immunisation system, bolstering global health security, and achieving sustainable development goals. This integrative approach will not only address the current barriers but also create a resilient framework for future immunisation efforts.

Image caption/credit: During a polio outbreak vaccination campaign, Dr. Sohail Ahmed checks children for a finger mark indicating polio vaccination. Submitted by Sohail Ahmed - Pakistan. CDC Global via Flickr (CC BY 2.0)

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