Poverty and Social Analysis of Expanded Program for Immunization

Poverty and Social Analysis of Expanded Program for Immunization

Introduction:

Pakistan still has a long way to go before it achieves or comes close to the fulfillment of EPI objectives. This endeavor becomes particularly difficult due to the ongoing health sector governance challenges in Pakistan at the national and sub-national level. A regional analysis of the most basic childhood health indicators reveal how Pakistan lags behind in its future pursuit of a globally competitive labor force.

The Federal PC-I for EPI 2010-2014 envisions to provide immunization services all over the country including FATA, FANA and AJK. The main sponsoring bodies include Government of Pakistan (Health Division before 18th Constitutional Amendment) and Global Alliance for Vaccines and Immunization (GAVI).[1] The execution was the responsibility of Federal EPI program Implementation Unit in the Ministry of Health, Government of Pakistan. This office was placed under the Ministry of Inter-provincial Coordination after devolution however in current year’s budget this office has now been shown under executive control of Planning and Development Division. The operation and maintenance of EPI as per PC-I remain mutual responsibility of national, provincial and Special Areas EPI units in the Provincial Departments of Health.

After providing a detailed literature review this report points towards the following gaps in the literature. Some of these gaps pertaining to poverty and social impact of EPI have been answered in this report.

• A scientific inquiry into regional differences in the performance of EPI as an organization is missing across literature
• The impact of climate change induced disasters and conflict on EPI progress has not been quantitatively investigated
• An across time evaluation of the political and cultural factors on the effectiveness of the EPI is missing
• Studies at the national level are mostly qualitative or descriptive and lack rigorous empirical analysis
• No impact assessment of local area strategies on EPI activities for the poorest women and children
• The impact of 18th Amendment and future expected developments in this context have yet to be studied exhaustively with stakeholders
• Several actionsdesired towards implementation of EPI, in literature keeping socio-economic, cultural and institutional factors in account have not been followed up with policy practitioners. Reasons for this gap between academia and practitioners require a careful inquiry
• The missing synergies between EPI and other health sector initiatives at national and sub-national level require a careful study
• A study showing the caveats in conducting the National Immunisation Days versus strengthening the routine immunisation services would be pertinent since the polio eradication over the last decade through NIDs has been far from successful
• Income and poverty impacts of EPI have never been quantified for Pakistan’s case. 

The household survey conducted as part of this report along with focus group discussions and key informant interviews have updated the existing knowledge on the tasks requiring attention at various administrative levels in health sector (and EPI in particular). At the federal level the tasks poorly addressed include: long-range policy planning for national health goals/indicators and targets; human resource planning in health sector, ensuring minimum service delivery standards; timely releases of federal funding; variance between allocations, releases and expenditures; ambiguous procurement procedures; bridging caveats which restrict funds flow to the provinces and hinder the planning and implementation of activities as directed by Council of Common Interest (CCI); and communication channels between national and sub-national units.

At the provincial level the tasks awaiting attention include: improvising and contributing resources with the federal funding given the greater fiscal space in the aftermath of the 7th NFC Award; regular identification of lacunas in program implementation; regular review of supply chain management; annual review of staff motivation issues and incentives structure; data collection and management systems; region-specific capacity building of manpower; improving reporting capacities; customizing public awareness campaigns according to region-specific challenges; preparing separate operational strategy and manpower for EPI routine services and NIDs; institutionalizing M&E processes; providing M&E feedback to provincial and sub-provincial officials; integrating those vertical programmes which have synergies and complementarities hence bringing in cost efficiencies and economies of scale; and exploring synergies with other provincial health sector programs and pooling resources for better utilization of resources.

At the district or local level there are issues related to: inadequate personnel and staff; inadequate incentives for on-ground staff; poor on-ground supervision; frequent multi-tasking (e.g. simultaneous NIDs and routine immunization); constraints on mobility of vaccines and vaccinator; political interference in recruitment; lack of local ownership of EPI activities and overcoming the cultural barriers through involvement of local stakeholders like religious and political leaders and where present civil society and community based organizations in addition to the NGOs.

Owing to the above mentioned issues our household survey revealed uneven performance of EPI across Pakistan. For the select districts surveyed the position of fully immunized is as follow. A comparison of our findings with alternate survey exercises is also provided in the report.

Our economic analysis reveals that the total number of incremental lives saved as a consequence of EPI activities is around 0.3 million out of which 0.19 million is in rural areas. Furthermore our conservative estimate reveals that the incremental lives saved under EPI contributed Rs. 11358 million (in 1993-94 prices) towards overall gross domestic product. This growth contribution and related factors led to 8 percentage point decline in poverty headcount on average over the decade of 2000s. The Gini coefficient a measure of inequality also remained lower by 5 percentage points on average during 2000s due to EPI activities.

The report argues for several policy and practice level reforms for EPI in Pakistan. First in order to pull together the fragmented administration of EPI the federal government needs to reorganize its operations. Currently while the EPI office is under executive control of Ministry of Inter-provincial Coordination and Planning and Development Division, the Inter-provincial Committee on Polio is based in Prime Minister’s Secretariat. We recommend here to expand the purview of this committee to include all 8 preventable diseases that fall under EPI.

Second there is weak futuristic forecasting for EPI services at provincial levels. Therefore suggestion is to establish Planning Cells in Provincial EPI offices. These cells should be tasked with revisiting area-specific indicators and targets, carry out area-specific analysis of program coverage, service availability and utilization. Furthermore these cells should also be tasked to deliberate on program sustainability.

Third while monitoring at local level is envisaged in the PC-I document the monitoring, evaluation and feedback system needs to be strengthened in the provincial and sub-provincial EPI offices. The feedback system should be responsive to currently absent grievance redressal mechanism. Such a mechanism is essential to develop a pull from the demand side. Initiatives such as social accountability can also help in strengthening grievance mechanism.

Fourth greater technological augmentation is required for vaccine stock management. Currently there is weak reporting and accountability of expired or heat affected vaccine stock. We have recommended that centrally monitored GPS systems at provincial offices should be introduced which should be able to see live and real time temperatures of vaccines in cold rooms and vaccine under transportation.

Fifth there is a need to rectify the incentives structure in order to ensure a motivated staff on-ground. We have recommended performance incentives however usual checks and balances are required in order to prevent any misuse of these incentives.

Sixth, Linking of EPI with NADRA offices has become extremely important. Currently population records are not being validated through birth registration. While there is a need in the medium term to make birth registration mandatory across rural and urban regions, there are ways through which the government can incentivize the parents to make such registration with immediate effect as well. For this purpose we have pointed towards Brazilian case study.

Seventh, EPI staff face great difficulty in providing services to people on the move. This usually happens during disaster or climate change-led migrations in Pakistan. For this purpose we recommend linkage between EPI and provincial disaster management authorities in Pakistan. NADRA will again have to come in the loop in order to provide migration statistics as validated by provincial disaster management authorities.

Eighth, reinforced effort is required in order to restructure and customize public awareness campaigns across the country. The strategic communications plan needs to be revised in order to take account of post-18th Amendment changes. For this purpose synergies should also be developed with other health sector initiatives – most of which have a component on public awareness.

Ninth, we recommend a public-private sector working group on EPI in order to discover the opportunities that may exist for private sector in Pakistan to get involved in the EPI supply chain. We have mentioned instances from India and Bangladesh where private sector is supporting the government in meeting its coverage targets. Similarly we have also recommended that a separate national working group may deliberate on focused intervention in conflict-prone areas of Pakistan.

Finally and in view of the lacking motivation amongst EPI staff on-ground and lack of intellectual capacity or reform there local area work places we recommend annual mandatory trainings and ideas exchange opportunities. Such venues will give them an opportunity to exchange the lessons learnt and witness home-grown best practices.