A total of 34 key informants participated in this study (Table 1), including officials from the Ministry of National Health Services, Regulation and Coordination and provincial Departments of Health, federal and provincial EPI managers from all five provinces and regions of the country and key informants belonging to partner organisations. Main themes emerging from these discussions are summarised below. In support of our structural interpretations of what participants said, we use textural descriptions (quotes in italic text) to substantiate the point .
The participants discussed several challenges currently being faced by the immunisation service delivery. Foremost is the confusion of whether to provide vaccination at fixed centres or through mobile outreach activities. According to a participant from Punjab, “The immunisation services provided through outreach are costly and cannot last for long, but the difficulty is that after many years of door-to-door campaigning for polio, people expect that all immunisation will be delivered at their doorstep.” Agreeing to this, others also expressed that both options need a forthcoming involvement of the health staff outside of EPI. According to a participant from Khyber Pakhtunkhwa (KP) province, “Health centres that serve as fixed sites have only one or two positions of vaccinator versus a bigger number of other staff (e.g. doctors, paramedics), whose conduct towards patient impacts community’s perception of quality of services, including immunisation. For outreach, likewise, the vaccinator needs support from LHW [Lady Health Worker] to mobilise families for getting their child vaccinated at the outreach point.”
Inequity in service delivery was also mentioned as a major challenge. Despite efforts, EPI is unable to plan for and provide services to the mobile, marginalised and hard-to-reach populations. Referring to districts from southern Punjab and KP, a participant from federal EPI said, “Immunisation service delivery to the marginalised, to populations in hard to reach areas, people in urban and peri-urban slums and nomadic population has been a critical issue due to lack of proper planning.” A closely connected point, which is also a solution, is the issue of population estimates. The EPI programme requires accurate information of the target population at the district (and below) level to rationalise the number of outreach teams. Providing this information falls outside the scope of EPI, and mainly with the census organisation. “Our estimates of populations, required amount of vaccines and personnel that will provide vaccination services are based on estimated additions to the number of population that we have from 1998 census. This estimation may be highly flawed leading to inadequacies in service delivery”, shared a participant from KP.
There are approximately 7000 fixed centres to provide EPI services to the target populations. Participants from provincial level thought there is a significant mal-distribution of vaccinators at the facility and community level, and additional vaccinators, especially females, are required. Their main concern, however, was about the lack of capacity-building mechanisms for the foot soldiers of immunisation. “Although EPI policy mentions the number of vaccinator per union, there is no clarity about the on-going training, capacity-building and results-based monitoring. Only one-time training of vaccinators provided at the time of induction is not enough; refresher trainings are required. The lack of performance reviews of the vaccinators and other staff is a key bottleneck and needs to be examined”, expressed a participant from Sindh province.
Lack of human resources and capacity appears even bigger at the federal and provincial levels. Managers at these levels have gigantic tasks, including country- or province-wide planning, procurement, logistics, leveraging funds, addressing community perceptions and managing hostile media. Inadequate number of staff and capacities at these levels pose huge impediments. Coupled with this is a dearth of succession planning and recurrent transfers within management tiers, that lead to a loss of institutional memory and limited levels of knowledge transfer. A participant from the federal level suggested, “A provincial situational analysis led by health department along with provincial programmes is necessary to document the required capacities at respective levels including a HR [Human Resources] registry mechanism at district and provincial level to inform a robust and dynamic HR strategy.”
Health information system
Almost all participants talked about issues in data along with room for improvement in the data credibility and accountability. The current lack of accurate information about the target number of children leads to inaccurate planning, false reporting and pilferage of resources. A participant from KP said, “In the absence of census during past 20 years, no accurate number is available about the children from a catchment area. As a result the planners are always uncertain about the denominator because of which the percentage of children covered by immunisation services are never reliable.” They suggested a high level unit along the lines of a Prime Minister’s polio monitoring cell, with adequate technical depth to monitor and analyse the data at union council, district, provincial and national level.
Even if fresh census data are available, there is still a need for a mechanism to carry out ongoing micro-censuses to accurately update the number of newborn children. This is being done by community-based vaccinators in 11 high-priority districts for polio, and should be achieved for RI through Lady Health Workers, who work throughout the country. “There is no single and comprehensive source of family data that vaccinator can use to plan their demand and ultimate delivery of the vaccine. Micro-census in both urban and rural areas is the solution to ascertain the correct denominator of children to be vaccinated”, was the statement of a participant from KP.
Essential medicines (vaccines and supplies)
While most of the participants from higher levels opined that vaccine supply and availability is satisfactory, those dealing at the district (and below) level did not completely agree to it. According to them, stock-outs do occur due to inaccurate estimations and cumbersome procedures. For example, a participant from Balochistan province shared, “Looking from the top, supply of vaccines may seem fine but stock-outs ranging from one to three months do occur at district and below level, mainly due to budget deficit for vehicle maintenance and fuel.”
They also highlighted the importance of accurate recording and reporting of vaccine availability, its storage, utilisation and wastage, citing a few examples where vaccines were apparently being consumed but not actually administered. “In the absence of accurate population estimates, the data about forecasting of vaccines and their use becomes flawed. At places, the targets are achieved but there still are a significant number of children waiting to be vaccinated. At others, vaccines get expired and dumped inappropriately as enough number of children are not found”, was shared by a participant from federal level.
Another point was about the devolved responsibilities, time when vaccine procurement will become a provincial responsibility. If procurement is to devolve as suggested, an important question is whether provinces are prepared regarding procedures and whether the federal government has informed them about these, along with providing technical assistance and necessary infrastructure. “It is important for the higher levels to assess whether the provincial and district storage capacity is up to the mark, whether back-up plans for power failures are available and working at all health facilities, and when and how the logistics and vaccine management software can be introduced at provincial and district levels”, was the concern shared by a participant from Sindh province.
The Government of Pakistan, with assistance from development partners, finances the immunisation services in the country. The bulk of resources come from GAVI/UNICEF for purchasing vaccines, while the government takes care of salaries of EPI staff, supplies and stationery, and other requirements like vehicle fuel and maintenance. Bottlenecks are usually faced in securing the government’s share. A focal person for district monitoring from Balochistan province shared, “Under the current budgetary arrangements, shortages in fuel and repair or maintenance budgets frequently occur, leading to restricted field visits of vaccinators and the monitoring staff. Likewise, immunisation cards are usually short in supply and as a replacement, the date for next visit is written on a small piece of paper and handed over to parents.”
The budgetary issues and their solutions lie with the broader governance system. The annual budgetary allocations for health are approved by legislature, handed over to provincial health department, and ultimately to the District Health Officer (DHO). The DHO has to release funds for EPI from the same kitty, where different priorities compete with each other, leading to slowing down of the process. A separate budget line for EPI can help in rapid transfer of funds through all levels. “Look at the innumerable responsibilities of a DHO and the priority that curative services usually take over the preventive programmes. The solution is a separate budget line for preventive programmes including EPI. This decision of creating a separate budget line, however, depends on provincial minister and secretary, EPI having no say in this decision”, was the submission of a participant from the Punjab province.
Governance and leadership
The participants discussed the overall structure of the immunisation programme organised within the wider governance system. They also discussed the position and power of different actors, placed at different hierarchical levels. “Bottlenecks in governance include the lack of transparency, accountability and regular programme reviews. When it comes to accountability, the performance of vaccinator is usually mentioned, while that of higher levels, tasked with programme planning and capacity-building, is conveniently ignored. At the same time, it is also true that federal and provincial levels have a lack of human resource and capacity and the increase in number of key positions at these levels is the mandate of wider system and not the EPI”, was a sentiment shared by a participant from KP.
Coordination issues seemed particularly important to participants when they explained governance challenges that emerge from the implementation of RI and polio eradication through two separate arms of the same programme. Polio eradication, that works under EOC and not EPI at all administrative levels, uses the EPI workforce but has its own administrative, financing and reporting structure. “It is said that polio programme has developed better monitoring and accountability mechanisms. This may be true but the fact remains that being an offshoot, it’s mechanisms cannot perform the accountability of the parent programme, on their own. There has to be a policy direction from the health ministry or department – the creator and regulator of both these programmes”, suggested a member of a donor agency.
The participants were unanimous in that governance issues cannot be addresses by the same level of operations that created them and only a mechanism from higher levels can help address these issues. It is important to define the role of the national ministry and strengthen the mechanisms for inter-provincial coordination to improve the overall performance and integration of the immunisation services in the country. “Federal EPI cell and interprovincial coordination committee with representation from all provinces and regions should work together. A donor coordination forum for immunisation needs to be established with defined scope and responsibilities. Higher policy should provide directions for synergies between polio and EPI, and collaborating with private sector to cover huge discrepancies in vaccine coverage”, were the key steps suggested by a participant from Balochistan.
The participants shared how some of the global factors impact the immunisation system in Pakistan. Two of these, i.e. global interest in polio eradication and the war on terror, were most commonly mentioned. The global players have more interest in Pakistan’s polio eradication and, as a result, the political push and financial assistance for polio has been much more than for RI in Pakistan. This became highly intensified when polio showed a surge in 2014 and sanctions according to international health regulations were imposed on Pakistan. A participant from KP said, “In 2014, the growth in polio cases in Pakistan generated much discussion and debate ultimately causing the enforcement of travel bans as per international health regulations. Identifying the severity of the situation, an emergency centre [EOC] was established. Polio started receiving much more funding, visibility and authority, ignoring sometimes the fact that it was a strong RI that would ultimately guarantee the sustainable eradication of polio.”
While the participants were aware of global factors that impinge upon RI, they were equally mindful that such factors can be addressed by the wider governance because only that layer comes into contact with the global factors of security and regulatory nature. An EPI official from Punjab said, “Health ministry and the provincial health departments, along with the wider governance system have the opportunity to sit on the negotiation table with representatives of other governments and agencies. So, they are in the best position to forewarn about consequences of bilateral decisions. Similarly, when contentious decisions like participating in a war are being made, those at the table are the first to consider the consequences that a decision will bring to their people.”
The participants discussed several policy issues that implicate the immunisation system. Foremost is that health policy has always had focus on ‘sickness care’ rather than ‘preventing disease’ and ‘promoting health’ in the country. Though so-called policy documents seem to show the intent of prevention and promotion, the implementation usually betrays these. “If policy is a statement of intent, resource allocation is a practical reflection of that policy. Before devolution of health, most of public health exchequer used to be on hospitals, equipment, medicines and salaries. Almost all the preventive programmes functioned with support from international donors. This is true even today; EPI is an example where about two-thirds of programme support comes from international donors”, shared participants both from federal and provincial level.
Our discussions with participants from various levels also provided a big picture of the post-devolution phase. There seems to be some ambiguity of the mandate that federal and provincial levels have for EPI. The roles and responsibilities of federal and provincial programmes need to be clarified, with financial layout for the next 5-year period reassessed, in the context of devolution and provincial responsibilities. “The comprehensive Multi Year Plans along with operational plans for each year should be developed in each province to ensure better planning and implementation of the programme. There is a lack of information about the processes of allocating funds at the district level by relevant authorities, which needs to be made transparent”, was a sentiment shared by a manager from Sindh province.
The question of how to enhance coverage through the involvement of the private sector, that currently contributes only 3% of the total immunisation, was also discussed. The challenge is that the private sector is mostly unregulated and consists of all forms of medics and healers, many of whom do not have proper training or even a practicing license. Even the formally trained and licensed practitioners are not directly engaged by EPI, as it is not mandated. “The door-to-door micro census has often revealed families where all children had received polio drops during each campaign but had missed doses of routine immunisation because they routinely consulted a private physician who never advised about vaccinations. EPI should engage with these private physicians but being a public sector programme, it needs direction and facilitation from national ministry or provincial health departments”, shared a provincial manager.
The participants explained how, in the wake of 9/11, the global war on terror and the geopolitical situation of Pakistan and Afghanistan impacted polio eradication and other immunisation efforts in the country. The country, where polio cases were surging in 2013–2014, saw a significant drop when the security situation improved along the border between Pakistan and Afghanistan. A participant from the federal ministry shared, “Up until 2014, we were struggling with polio being reported not only from border areas but also from Karachi and other districts. Our immunisation activities were seriously affected as health workers were targeted and killed. It was in 2015 that territorial gains made by the Pakistani military in Wazirastan agency gave more access to vaccinator teams in tribal areas. The collaborations between Pakistan’s security forces and the polio teams helped achieve a reduction of over 80% in new polio cases reported that year.”
Community perceptions and practices
In their discussions, almost all interviewees talked about the demand-side issues and highlighted the need for addressing community misperceptions and facilitating their immunisation behaviours. According to them, it is mainly the conservative minded, blind followers of faith leaders, or nomads who usually refuse RI. “A common feature is that these people do not usually have enough knowledge of the purpose and benefits of vaccines; providing this information usually proves helpful. The challenge is that misperceptions may not be the same across provinces and districts; hence a blanket communication is less likely to work. Exploring the local factors and perceptions that may be acting as a barrier and integrating this with other public health communication is required”, stated a participant from federal EPI.
Participants also emphasised the importance of mass media and the need of being able to connect the locally implemented campaigns with the on-going health messages on mass media. According to them, the local and mass media components of the current communication campaigns do not complement each other, because of which the quantum of effect is lost. A participant from KP said, “Local campaigns should address the local misperceptions while also establishing a connection with the mass media messages, which are there to sensitise the masses on importance of immunisation while reinforcing the content being disseminated at the local level, at the same time.”