Vaccine 31 (2013) 33133319

Contents lists available at SciVerse ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Review

Pakistans expanded programme on immunization: An overview in the context

of polio eradication and strategies for improving coverage
Aatekah Owais, Asif Raza Khowaja, Syed Asad Ali, Anita K.M. Zaidi
Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan

i n f o

a b s t r a c t

DR

a r t i c l e

Article history:
Received 16 March 2013
Received in revised form 2 May 2013
Accepted 7 May 2013
Available online 22 May 2013

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Since its inception in 1978, Pakistans Expanded Programme on Immunization (EPI) has contributed signicantly towards child health and survival in Pakistan. However, the WHO-estimated immunization
coverage of 88% for 3 doses of Diptheria-Tetanus-Pertussis vaccine in Pakistan is likely an over-estimate.
Many goals, such as polio, measles and neonatal tetanus elimination have not been met. Pakistan
reported more cases of poliomyelits in 2011 than any other country globally, threatening the Global
Polio Eradication Initiative. Although the number of polio cases decreased to 58 in 2012 through better
organized supplementary immunization campaigns, country-wide measles outbreaks with over 15,000
cases and several hundred deaths in 201213 underscore sub-optimal EPI performance in delivering routine immunizations. There are striking inequities in immunization coverage between different parts of the
country. Barriers to universal immunization coverage include programmatic dysfunction at lower tiers of
the program, socioeconomic inequities in access to services, low population demand, poor security, and
social resistance to vaccines among population sub-groups. Recent conicts and large-scale natural disasters have severely stressed the already constrained resources of the national EPI. Immunization programs
remain low priority for provincial and many district governments in the country. The recent decision to
devolve the national health ministry to the provinces has had immediate adverse consequences. Mitigation strategies aimed at rapidly improving routine immunization coverage should include improving the
infrastructure and management capacity for vaccine delivery at district levels and increasing the demand
for vaccines at the population level. Accurate vaccine coverage estimates at district/sub-district level and
local accountability of district government ofcials are critical to improving performance and eradicating
polio in Pakistan.
2013 Elsevier Ltd. All rights reserved.

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Keywords:
Pakistan
EPI
Polio eradication
Overview

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3314
History and policy milestones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3314
Routine EPI vaccine coverage situational analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3314
Barriers to universal immunization coverage in Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3315
Strategies for improving immunization coverage in Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3316
5.1.
Improving EPI service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3316
5.2.
Integration of maternal-neonatal-child health and immunization programs and services under one directorate . . . . . . . . . . . . . . . . . . . . . . . . 3316
5.3.
Improving district level management capacity and accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3317
5.4.
Independent district level monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3317
5.5.
Increasing vaccine demand in the population through targeted education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3317
5.6.
Mass communication for vaccine promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3317
5.7.
Involvement of Civil Society Organizations (CSOs) and other stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3318
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3318
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3318
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3318

Corresponding author at: Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan.
E-mail addresses: aatekah.owais@gmail.com (A. Owais), raza.asif@aku.edu (A.R. Khowaja), asad.ali@aku.edu (S.A. Ali), anita.zaidi@aku.edu (A.K.M. Zaidi).
0264-410X/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.vaccine.2013.05.015

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2. History and policy milestones

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World Health Organization (WHO) launched Expanded Programme on Immunization in 1974 to address the inequities in
global vaccination coverage [1]. The goal of universal childhood
immunization against six antigens (tuberculosis, polio, diphtheria, pertussis, tetanus, and measles) was proposed at the World
Health Assembly in 1977 [1]. Pakistans EPI was formally initiated
in 1978. Until 1982, all vaccines were provided by WHO, after which
EPI activities were nanced through the National Accelerated Programme on Health, which had three main components including
EPI, Oral Rehydration Therapy and training of Traditional Birth
Attendants. From 198890, EPI in Pakistan was funded by a consortium including UNICEF, USAID and Rotary International. When this
consortium ended in 1991, EPI activities in Pakistan suffered from
lack of funding which led to shortage of vaccines and supplies. This
may have resulted in decline in vaccine coverage between 1991 and
1996 [2,3]. With the Ministry of Health providing the funding, the
national EPI Programme was revived in 199697. Today, with the
annual budget of more than USD 104 million per year [4], Pakistans
EPI targets 5.9 million pregnant women, and a birth cohort of 5
million, annually. According to ofcial estimates, EPI provides 97%
of the immunizations provided in the country, while 3% is provided
through the private sector [5]. The infant mortality rate in Pakistan
has decreased from 123 per 1000 live births in 1975 [6] to 78 per
1000 live births in 2006 [7], and many believe increasing access to
childhood vaccines has contributed to improving child survival in
poor countries [8,9].
The Pakistan National EPI follows the WHO recommended
immunization schedule for low-income countries. Until the year
2002, this included administrating BCG/OPV at birth, three doses
of DTP/OPV vaccine at 6, 10 and 14 weeks of age, and measles vaccine at 9 months of age. With the support of GAVI Alliance (formerly
called Global Alliance for Vaccines and Immunizations), Hepatitis B
and Haemophilus Inuenzae type b (Hib) vaccines were introduced
into the national EPI program in 2002 and 2009, respectively. The
Hib vaccine is delivered as a combination injection comprising 5
antigensDTP-Hepatitis B-Hib and is commonly referred to as pentavalent vaccine. A second dose of measles, to be administered
in the second year of life, was added in 2009, and pneumococcal
conjugate vaccine has been approved for introduction in 2012.
Hasan et al. [4] from WHO Pakistan and the National EPI recently
published a comprehensive review of EPI in Pakistan. Immunization
delivery in Pakistan is undertaken by 10,000 trained vaccinators
and 6000 Lady Health Visitors (LHVs) and other paramedics. More
than 100,000 Lady Health Workers assist in this process by social

DR

Pakistans National Expanded Programme on Immunizations

(EPI) is facing a harsh spotlight because of the failure to eradicate poliomyelitis in the country and a large measles outbreak in
2012. Pakistan reported more cases of poliomyelitis (198) than any
other country in 2011, also representing more cases than in any
year in the previous decade. A major underlying factor for continued poliomyelitis and measles transmission is failure of routine
immunization programs to reach millions of children, including the
inability to mount high quality supplementary immunization activities (SIAs) that would reach children in all areas of the country.
This review focuses on the performance of Pakistans EPI, with an
overview of the history, current effectiveness of the program and
SIAs, barriers to improving coverage, and strategies for strengthening program performance. Attention to Pakistans EPI is essential
if Pakistan is to meet polio eradication and measles elimination
targets.

mobilization, defaulter tracing and occasionally providing vaccination services. There are 6000 xed EPI centres, approximately 1 for
about 27,000 population, though there is wide variation in coverage from district to district, and even at sub-district levels. Various
supplementary immunization activities, such as National Immunization Days for polio and vaccine specic mop-up campaigns
are organized in order to increase immunization coverage among
high-risk populations.
Pakistans EPI Programme is governed by the National EPI Policy. This policy was re-formulated by the National EPI advisory
Group (NEAG) in 2004, and was successfully adopted by the Ministry of Health in 2005. The National Immunization Technical
Advisory Group (NITAG), a continuation of NEAG, was formed in
2009. The Groups aim is to review program policies, and provide
evidence-based recommendations about the introduction of new
vaccines into the National EPI Programme. Pakistans National EPI
Policy has been revised in 2010 and is pending approval. Since
Pakistan is among GAVI eligible countries, the government, following NITAGs recommendations, has prioritized the introduction of
the new pneumococcal and rotavirus vaccines into the National
EPI Programme. The long-term impact of the June 2011 decision of the Government of Pakistan to close down the national
Ministry of Health, and devolve powers to the provinces on the
existence and functioning of the National EPI is currently uncertain. The National EPI now exists as a cell within the Ministry of
Inter-Provincial Coordination. Early indications are of signicant
short-term adverse impact with lack of funds centrally for important functions such as maintaining cold chain storage for vaccines in
the capital, Islamabad, and transport of vaccines to provinces, and
lack of clarity about who is responsible for procurement, and who
will deal with the partner agencies involved in assisting Pakistans
immunization activities (UNICEF, WHO, and GAVI).

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3. Routine EPI vaccine coverage situational analysis

The overall immunization coverage estimate for three doses
of Diptheria-Tetanus-Pertussis (DTP3) and OPV vaccine Pakistan
is 88% [10], but the validity of these vaccine coverage estimates
is questionable [11], especially in light of widespread occurrence
of poliomyelitis cases in 58 districts of Pakistan in 2011. Accurate
estimates of vaccine coverage in Pakistan are hard to come by. Vaccination cards are often missing, even if the parents report that their
child was vaccinated, resulting in some coverage estimates based
on verbal recall, which may over-estimate the number of children
immunized, especially in Pakistan. Sheikh et al. [12], using serological conrmation, showed poor correlation between verbal recall
and serological immunity for measles in Karachi, Pakistan.
On the other hand, using card veried data only, results in
under-estimates of coverage. There are no vital registration records,
or computerized immunization registries. Hand-written, poorly
maintained immunizations registers with illegible writing abound
at EPI centres. It has been over 14 years since the last census. Therefore, the number of children needing immunization in a particular
district or union council (administrative unit tier after district) is
not known. Other deliberate sources of bias may also exist, leading to over-reporting of vaccine coverage by district authorities.
Universal Childhood Immunization campaign and GAVIs immunization services support program provide performance-based
incentives that may encourage support-recipient countries to overreport coverage estimates [11]. A recent study estimates that the
number of additional children reported to have been immunized
with DTP3 between 19992006 in Pakistan may have been overestimated by more than four-fold [11]. Table 1 summarizes the
difference between ofcial estimates and independent evaluation
of immunization coverage in Pakistan by antigen.

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Table 1
Difference in ofcial estimates and independent evaluation of immunization coverage in Pakistan by antigen.
Antigen

Ofcial estimatea

Independent evaluationb

BCG
Polio-3
DTP3/Penta-3
Measles-1

90
85
85
80

80.3
83.1
58.5
59.9

present in immunization coverage even in large cities such as

Karachi.
The infrastructure of the EPI still has signicant gaps [4]. The
National Policy recommends two vaccinators per union council
(UC). However, only 1.3 vaccinators per UC are actually available.
Except for Sindh, which has 115% of the required vaccinators, Punjab, Khyber- Pukhtoonkhwa (KP) and Baluchistan have only 52%,
70% and 72% of the required vaccinators, respectively. There is also
considerable variation in the number of xed EPI centres available
per unit population in the different districts of each province.

Ofcial estimate reported to WHO-UNICEF, 2009.

Pakistan Demographic and Health Survey, 200607.

4. Barriers to universal immunization coverage in Pakistan

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Many studies from different regions of the world have studied factors that contribute to low immunization coverage and/or
high immunization drop-out rates. Low maternal literacy, especially health literacy, poor socioeconomic status, and difculty
in accessing immunization services have been identied as the
main barriers to immunization completion [1728]. There is also
evidence suggesting that stunting in the child and parental education can affect vaccine seroconversion [29]. Pakistan faces all of
these challenges and more. A population size of almost 180 million, one of the largest birth cohorts in the world (estimated 4.8
million in 2012), and the geographical complexities of mountains
and glaciers in the north, and dispersed populations in the vast
lands of Baluchistan make public health service delivery in Pakistan
uniquely challenging. The median years of schooling completed is
3.3 years for women living in urban Pakistan, and 0 years for women
living in rural areas of the country [7]. Approximately two-thirds
of the population lives in rural areas [7], with one-third living on
less than US$1 a day [13].
Pakistan has struggled with decades of less than ideal governance, both at the federal and provincial/district level. With less
than 2% of countrys GNP spent on health [30], immunization
against childhood diseases has historically been a low priority for
the countrys leaders. It has only been in past few years, with the
nancial and operational impetus from rst the Polio Eradication
Initiative, and more recently the GAVI Alliance, Bill and Melinda
Gates Foundation, and the WHO/UNICEF Global Immunization Vaccine Strategy (GIVS), that immunization against childhood diseases
has become a public health priority in Pakistan.
Poor investment in health service infrastructure in many parts
of the country and the lack of district level management capacity

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There are also signicant inequities in immunization coverage

at the provincial, district, and sub-district level. For example, the
WHO/UNICEF reported national DTP3 coverage of 73% [13] hides
the inequity in immunization coverage between Baluchistan (32%)
and Punjab (76%) in 2006 (see Fig. 1). Furthermore, although EPI
district level data shows >80% coverage of Penta-3 and measles vaccines in more than half the districts, disaggregated data is needed to
assess the level of inequity prevalent at the sub-district level. Typically, sub-district immunization coverage levels are low in those
areas most in need of immunization services.
Various studies conducted at district and sub-district level in
the province of Sindh report immunization coverage levels ranging from 5575% [12,14,15]. Shaikh et al. [14], working in 9 Union
Councils of Khairpur (northern Sindh), reported an overall DTP3
completion rate of 72%, with immunization coverage as low as
50% in some areas. Another study conducted in the rural district
of Matiari in 2008 found DTP3 coverage at 79.5% [16]. The study
identied the presence of Lady Health Workers who were locally
resident as an important determinant of higher immunization
coverage in the district. A geographically and socio-economically
representative sample of the population of Karachi, conducted by
researchers at Aga Khan University reported DTP3 coverage among
1223 month old children of 75% [38]. Another population representative survey, estimating the proportion of measles susceptible
children in Karachi, found measles antibodies in only 55% of children, 12 59 months old [12]. This study was conducted one year
after the nationwide measles supplementary immunization activity (SIA) of 200708. Only 3% of respondents reported that their
child had received the measles vaccine through the SIA [12]. A more
in depth survey of low-income communities, conducted in periurban areas of Karachi reported DTP3 coverage of 46.5% (Khowaja
et al., unpublished data). These ndings highlight the inequities

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b

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100%

90%

60%

Coverage

76%

76%
73%

70%
60%
50%

86%

84%

80%

49%
45%
40%

40%

62%

62%
57% 55%

63%

60%
52%

54%

53%
47%

39%

37%
32%

49%

35%

30%
20%
10%
0%
1995-96
Pakistan Integrated
Household Survey

2001-02
Pakistan Integrated
Household Survey

2004-05
Pakistan Social and
Living Standard
Measurement

2006
EPI Coverage
Evaluation

2006-07
Pakistan
Demographic and
Health Survey

2011
National Nutrition
Survey

Survey
Punjab

Sindh

KPK/FATA

Baluchistan

Fig. 1. DTP3 immunization coverage by province, 19952011.

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A. Owais et al. / Vaccine 31 (2013) 33133319

are also least likely to participate in NIDs and SNIDs [42]. Therefore, strategies aimed at improving EPI coverage in Pakistan need
to target these high-risk populations.
5. Strategies for improving immunization coverage in
Pakistan

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Historically, the main thrust of efforts aimed at increasing

immunization coverage rapidly in a population has been through
mass immunization campaigns. This strategy has been quite successful [43]. Since 1988, polio incidence has decreased by >99% [44],
and measles-associated mortality has declined by 78% between
2000 and 2008 [45,46]. Pakistan has now had more than 110 mass
polio immunization campaigns. Although effective in decreasing
the incidence of polio, mass vaccination campaigns have been
unable to interrupt the transmission of poliovirus in the country
due to the inability of vaccinators in reaching children in areas
of conict, migrant and marginalized populations, or where there
is social or passive local governmental resistance to polio vaccine
campaigns. On the other hand, in countries that have invested in
establishing strong routine immunization services, or in very high
quality supplementary vaccination campaigns, polio eradication
has been achieved successfully.
The following is a brief discussion of 7 proposed strategies,
which may lead to improved routine immunization coverage in
Pakistan (see Panel 1).
5.1. Improving EPI service delivery
Investments in strengthening EPI infrastructure are critical to
improving EPI coverage. Increasing the number of static EPI centres,
increasing the hours of operation to 5 pm, and increasing the number of vaccinators assigned to each centre, is necessary to ensure
maximum utilization of these facilities. More than 100,000 LHWs
currently assist in supportive EPI activities, such as parental counselling and tracing defaulting children. These LHWs can be trained
to administer vaccines, which can help overcome the limited number of vaccinators available. Indeed, several thousand LHWs have
recently been trained using GAVI Health System Strengthening
funds, but are yet to be deployed in routine immunization activities.
The 2010 National EPI Policy provides excellent guidance for
improving immunization services delivery. Four important recommendations include: (i) requiring all public sector healthcare
facilities to have a functioning EPI centre; (ii) LHWs trained in EPI
service delivery should provide immunizations in their catchment
areas through designated community-based vaccination sites; (iii)
all static EPI centres should provide immunization services on all
working days; and (iv) children should not be denied vaccinations
for reasons of not wanting to open vials of certain multi-dose vaccines, such as measles, because of excessive concern about wastage.
Ensuring implementation of the 2010 National EPI Policy would
constitute a huge step towards achieving universal immunization
in Pakistan.

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to deliver vaccines, and accountability have been major barriers

to improving immunization coverage in these areas. The situation
has been further exacerbated by the increasing shortage of power
supply and frequent load-shedding in both rural and urban areas,
potentially damaging vaccine quality because of inadequate cold
chain maintenance [31].
Periods of conict and/or natural disaster also result in the
destruction of healthcare infrastructure and services [12,32]. Over
the last decade, Pakistan has suffered from both large scale natural
disasters and conict that have further weakened the health and
immunization infrastructure in Pakistan [31,33]. The large numbers of population displaced internally because of these disasters
has created logistical and operational challenges that have severely
stressed the already constrained resources of the country. Pakistan
was the only country in the world where the number of polio cases
increased in 2010, from 89 in 2009 to 144 in 2010. Most of these
cases were traced back to the tribal areas in northwest Pakistan,
where on-going ghting between militants and the Pakistani army,
the US-led war-on-terror, and killing of vaccination teams by
local militants has affected provision of both routine immunization
services and polio SIAs.
Frequent National Immunization Days (NID) and Sub-National
Immunization Days (SNID) are held in Pakistan as part of the
countrys polio eradication campaign. While the infrastructure
developed for this campaign could have been used to improve routine EPI coverage, this has not been the case in Pakistan. There is also
evidence that SIAs may be limited in their ability to reach children
most likely to not use routine immunization services [34]. Furthermore, the authors (ARK, AKMZ) structured eld assessments in
rural and urban Sindh indicate that EPI routine immunization services are affected during polio NIDs compared to baseline status
(unpublished) as vaccinators are deployed in campaigns. During
a NID, vaccinators also receive an incentive of Pakistan Rs. 150
($1.50) per day. No such incentive is available for providing routing immunization services, creating the perception that mass polio
vaccine campaigns are a higher priority than routine immunization.
Some public health researchers have argued that door-to-door supplementary immunization campaigns may create an expectation
in the parents minds that all vaccines will be delivered at home,
paradoxically reducing the demand for routine EPI vaccines delivered at health centres and resulting in lower routine immunization
coverage [3537]. The impact of mass polio eradication campaigns
on routine EPI needs to be documented systematically through a
formal monitoring process.
A representative survey of Karachi, conducted by the Department of Paediatrics and Child Health at Aga Khan University
highlighted parental misconceptions as one of the major reasons for
children not getting vaccinated [38]. The survey was conducted in
42 clusters, covering all 18 towns of Karachi, representative of people belonging to low, middle, as well as high socioeconomic strata.
Among those surveyed, 75% of the children had complete coverage
up to third dose of DTP. Parents of the 25% children who were not
vaccinated were interviewed to explore their reasons for not vaccinating their children. Major reasons identied were vaccines can
harm the children instead of beneting them, elders in the family
had asked not to get the child vaccinated, vaccines are for family
planning purposes, and vaccine caused high-grade fever in the
older sibling, so I did not get the younger one vaccinated. Another
stated reason was the mother being alone at home. EPI infrastructure issues, such as distance to vaccination centre and absence of
vaccinators at the centre, were also highlighted.
Ethnic/racial disparities in healthcare access and utilization are
common even in high-income settings [3941]. Therefore, it is not
surprising that these exist in routine EPI coverage in Pakistan too.
Pashtun and Bengali families have been found to have the lowest
routine immunization coverage in Pakistan [38]. Pashtun families

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3316

5.2. Integration of maternal-neonatal-child health and

immunization programs and services under one directorate
Multiple vertically-run programs are currently responsible for
improving maternal-child health in the country, creating inefciencies, silos, and dysfunction, and functioning as barriers to
improving immunization coverage. For example, the agship governmental program for improving population health in Pakistan,
the Lady Health Worker Programme, which could play a critical
role in improving routine vaccination coverage in the country, is
administered separately from the EPI Programme. Another obvious
example is the lack of integration between curative and preventive

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health services offered within the same health facility. Most EPI
centres function within health facilities such as Basic Health Units
(BHUs), Rural Health Centers, and District as well as teaching hospitals, offering curative services for children, but functional integration between immunization services and curative health services
is entirely lacking. There is tremendous opportunity presented by
the recent devolution of all health programs to the provincial levels
to integrate all programs addressing maternal and child health and
survival into one unit at the provincial and district levels, responsible for delivery of an essential package of health services to the
population, including immunization services. The Peoples Primary
Healthcare Initiative, running in several districts, but providing
only curative services at the BHU level may be one program which
could also be responsible for providing vaccinations at the BHUs.

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Lack of accountability and weak management is a crucial factor

in the failure of routine immunization program in Pakistan. Political
appointments and frequent transfers of district health and executive ofcials adversely affect program performance. Improving
district-level management and nancial capacity to deliver vaccines, motivating and training staff to perform optimally, timely
and adequate remuneration, and ensuring accountability at district level, is critical to improving immunization coverage in the
country. District health decision makers should be required to
have specic immunization program management training covering all aspects (inventory management, nancial management,
technical knowledge of vaccines and vaccine programs etc.) before
appointment to such posts. Such training courses can be offered
through the National EPI and other public health or academic institutions/organizations with the requisite expertise.
The WHO recommended Reaching Every District (RED) strategy
should be adopted for operational planning, implementation and
monitoring. This strategy has been successfully implemented in
many low-income countries, and has resulted in improved immunization service delivery [47,48].

Honduras that provided cash transfers to families with young

children who underwent regular health check-ups. Among households receiving cash transfers, well-child visits to health centres
increased by 1520 percentage points (p < 0.01), providing an
opportunity to immunize those children, and increasing the rate of
DTP1 completion by 7 percentage points. Juntos in Peru, is another
example of a conditional cash transfer program that was successful in improving immunization coverage among young children.
Among the Juntos families, the number of age-appropriately immunized children <12 months increased by 30% [50].
Signicant evidence in support of demand side strategies for
promoting immunization services is now also accumulating from
Pakistan. Owais et al. [52] conducted a randomized controlled trial
to assess the impact of low-literacy vaccine promotion educational sessions conducted at homes of mothers of infants <6 weeks
old, living in semi-urban Pakistan. They found that DTP3 completion rates improved by 39% in the intervention group whose
parents received home education by community health workers.
Usman et al. [28] report an improvement of 18% in immunization completion rates among infants whose mothers received a
23 min education session on the importance of vaccines. These
messages were conveyed by trained staff to mothers of infants who
presented at primary health clinics in urban Pakistan to receive
DTP1. Chandir et al. [49] conducted a longitudinal cohort study to
assess the impact of food coupon incentive on timely completion
of DTP immunization among children living in low-income areas
of Karachi, Pakistan. They report a more than two-fold (RR 2.20;
95% CI: 1.952.48) increase in the immunization completion rates
of children in the cohort who received the incentive.
Another simple strategy to improve immunization coverage is
to encourage the retention of immunization cards by parents as
reminders [17,22]. Usman et al. [28] report a 25% improvement
in DTP3 completion rates in the group who received a redesigned
immunization card, aimed at mothers with low literacy to remind
them about the next immunization visit. An improvement in vaccination card retention was also observed in the participants of Hib
vaccine impact study being conducted by the Department of Paediatrics and Child Health, Aga Khan University, in Hyderabad and
Matiari (Sindh). EPI centres are provided with plastic pouches to
give to mothers to store the childs immunization card. This has
resulted in almost universal card retention in the areas under study,
making it much easier to verify the immunization status of a child.

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5.3. Improving district level management capacity and

accountability

3317

5.4. Independent district level monitoring and evaluation

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Accurate vaccine coverage estimates at the district level are

essential to monitor and evaluate program performance and ensure
district-level accountability. These should be supplemented by
serological surveys at bi-annual intervals where possible [12], and
GAVI Alliance support should be made conditional upon the existence of independent estimates of vaccine coverage at district level.
Managers of poorly performing districts should be held accountable
for their work.
The 2010 National EPI Policy calls for more rigorous monitoring
at the district level. The policy states that one-third of all EPI centres and 30% of all district-level immunization outreach activities
should be visited by the district supervisor and/or supervisory staff
every month.
5.5. Increasing vaccine demand in the population through
targeted education
There is an increasing body of evidence that suggests that
interventions that aim to increase the demand for vaccines and
immunization services at the population level are successful
strategies for improving immunization rates [28,4953]. These
interventions include educational messages, conditional cash
transfers, and food coupons as incentives to families for ensuring
immunization completion for their children. Morris et al. [51]
report the outcome of a cluster randomized trial carried out in

5.6. Mass communication for vaccine promotion

The pursuit of mass communication for vaccine promotion
should be seen as a three-step process, with the assumption that
everyone can communicate the value of vaccines. Seeking partners
for mass communication efforts for vaccine promotion should be
formalized into a precise, methodologically sound case. Audiencespecic, rather than a universal plan for communication needs
to be envisioned and instituted in conjunction with all key players, including current and potential stakeholders and the target
population, to address the heterogeneity that exists within, and
amongst them. A tailor-made argument would be much better
understood and accepted, since the recipients would be able to
relate to it. Second, the scope and impact of the roles and responsibilities of the distinct entities in the advocacy and communication
network should be clearly dened as a function of the resources
they enjoy. For example, school teachers should educate children
and their parents about the importance of immunization, whereas
a community-based organization should target an entire community by liaising with its elders. The inclusion of a training module
on childhood immunization in medical and paramedical school
curriculum would enable development of vaccine champions. Last,
the aforementioned efforts should be formally monitored and

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A. Owais et al. / Vaccine 31 (2013) 33133319

I. Improving EPI service delivery

Increase the number of static EPI centres, hours of operation,
and the number of vaccinators assigned to each centre, and
train and motivate staff
II. Integration of maternal-neonatal-child health and immunization programs and services under one directorate
Integrate all programs addressing maternal child health and
survival, including immunization services, into one unit at the
provincial and district levels
III. Improving district level management capacity and accountability
Improve district-level health management and nancial
capacity to deliver vaccines, with built in management training
relevant to EPI and appropriate accountability mechanisms
IV. Independent district level monitoring and evaluation
Accurate vaccine coverage estimates at the district level are
essential to monitor and evaluate program performance and
ensure district-level accountability.
V. Increasing vaccine demand in the population through targeted
education
Employ active interventional strategies, such as educational
messages, conditional cash transfers, and food coupons as
incentives to communities with low immunization rates
VI. Mass communication program for vaccine promotion
Branded EPI and vaccine promotion messages from the
media, societal and religious leaders is necessary to encourage
parents to get their children immunized.
VII. Formal involvement of Civil Society Organizations (CSOs) and
other stakeholders
CSOs can play a pivotal role in immunization service delivery
as well as communicating value of vaccines in the communities
in which they work

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Not-for-prot and/or civil society organizations could also be

involved in immunization promotion related communication and
advocacy, as well as service delivery. The contributions of Rotary
International (RI) towards polio eradication are note-worthy in this
regard. Since 1985, RI has contributed more than $800 million to
polio eradication programs around the globe.
According to a 2001 survey, Pakistan has approximately 12,000
registered CSOs [54]. These organizations provide communitybased health services in many areas of the country where public
sector health facilities are not available [55]. With support from
the GAVI Alliance, a new partnership between 23 CSOs and the
Ministry of Health (MoH) was established in 2007 for promoting vaccine uptake. Since then, these CSOs and MoH have worked
together on a number of activities, including polio eradication campaigns, developing manuals for training of EPI trainers, and routine
immunizations service delivery [55].
These public-private partnerships could build the crucial platform needed to ensure successful program implementation of
Pakistans EPI. First, in some areas of the country, CSOs enjoy greater
public respect and support, compared to the national, provincial and/or district government. Therefore, formally established
liaisons between CSOs and the government will improve program
credibility. Furthermore, these CSOs, by virtue of their close association with the communities, are not only well acquainted with
the dynamics of the populations they serve, but are also wellacquainted with each communitys self-prioritized concerns, such
as access to clean water, over and above childhood immunizations. Thus, solutions addressing these specic concerns could be
packaged, within the constructs of a micro-plan for an individual
community, as an incentive for getting every child vaccinated. Additionally, EPI could potentially harness the logistical infrastructure
of CSOs already in place in their communities, leading to major
cost-savings for the program.
Local religious leaders and community elders (e.g. mosque
imams) could be convinced to participate in immunization promotion to ensure universal acceptance of vaccines in their respective
communities. An ofcial training program could be conceived, in
consultation with the respective central religious authorities, to
formally educate local religious gures. Vocal support from religious authority gures was vital in ending the Nigerian polio
vaccine boycott [56] where the increased involvement of religious
and traditional leaders has led to improved acceptance of the polio
vaccine [57].

Panel 1: Suggested strategies for improving routine immunization coverage in Pakistan

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5.7. Involvement of Civil Society Organizations (CSOs) and other

stakeholders

to serious inequities in coverage across the country, the failure

to eliminate poliovirus transmission and large scale outbreaks of
measles. Comprehensive efforts are needed to rapidly strengthen
the EPI infrastructure and governance, address resource inequities,
ensure accurate estimates of vaccine coverage, and to increase
the demand for vaccines at the population level. Urgent attention
to the EPI in Pakistan is essential in the global ght to eradicate
poliomyelitis.

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evaluated to ensure consistencies and suggest improvements. In

addition to expanding the communication network manifold, such
a process would present a clear and distinct direction towards a
singular national goal.
One of the major barriers to universal immunization that would
benet from the above-mentioned exercise is alleviating parental
misconceptions and raising awareness about the benets of vaccines, to increase vaccine uptake in the population. Communication
of a branded vaccination promotion message from the media and
opinion makers should be sought as a priority. The Pakistan EPI
could benet substantially from a catchy jingle.

ap

3318

6. Conclusion
Pakistans EPI is facing many challenges, including sub-optimal
management and nancial capacity to deliver vaccines, conicts,
natural disasters, and low priority of routine immunization services in the face of the urgent need to eradicate polio. This has led

Acknowledgement
A. Owais was supported by a training grant from the Fogarty
International Center, National Institute of Health, USA (Grant number: ID43 TW0075 85-01). ARK has received partial funding support
from the same grant.
Conict of interest: All authors: no conict of interest.
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