Only those countries prosper and progress whose citizens enjoy the best health facilities and medication. It is of primary concern for every state to provide better health facilities, producing more doctors and medical staff with better expertise and specialization. It demands more scientific research and systematic study to identify the root causes and help in developing a devise strategy to deliver at the best level. Mostly a state cannot do alone on its own expense as needs a lot of resources and structural requirements with immense finance for these projects. So to overcome these issues, the world has evolved the ways to tackle the health problems involving its private sector to share the burden along educating the masses and eradicating the diseases.
Most of the analyst view this necessary to build a rapport among its public and private institutions and organizations for the curtailment of these diseases and better research techniques to identify and seek measures as well. In Pakistan, it is of same situation where most of the areas are under-developed and highly underprivileged. A cursory look on Health map of Pakistan shows very dangerous facts and bleak picture. Much is what missing in this picture to be offered to its citizens. The most common issue and widely noticed is immunization and its very low coverage which must be of top priority and serious measure be taken along brining the private organizations in loop for far areas to disseminate information and educating the masses along medication.
Low immunization coverage is the reason why many vaccine-preventable diseases continue to persist in Pakistan. Expanded Programme on Immunization (EPI) was initiated in Pakistan in 1978 with the collaboration of WHO and UNICEF. Its main objective was marked reduction in the morbidity and mortality of children due to six vaccine-preventable diseases i.e. diphtheria, tetanus, measles, pertussis, polio and tuberculosis. In addition, vaccination against Hepatitis B was included in EPI in July 2002. Though international agencies such as the WHO and UNICEF promote global immunization drives and policies, the success of an immunization programme in any country depends more upon national policies that take into stock ground realities.
The WHO has made tremendous efforts for the eradication of polio and cases have been reduced from 350,000 in 1988 to 1604 in 2009 due to regular immunization worldwide. Pakistan is considered among those few countries where polio is still present as an endemic disease. Neonatal tetanus and maternal tetanus also kill thousands of children and mothers all over the world. By July 2010, most of the countries achieved total elimination of Maternal Neonatal Tetanus (MNT), leaving 40 countries that still have this deadly disease.
Unfortunately, Pakistan is also included in those countries where more than 50% of the districts are at a high risk of Maternal Neonatal Tetanus (MNT). According to the WHO, one in every 11 children dies before turning five years due to pneumonia and diarrhea which are vaccine-preventable diseases. Recent measles epidemic caused 210 deaths in 2012 and 28 deaths in 2011. It clearly exposes the inadequate immunization programmes in Pakistan.
According to United Nations Development Programme [UNDP] (2011), although the rate of child death has been falling, the targets of Millennium Development Goals (MDGs) 2015 of reducing under 5 mortality to 52 per 1000 live births, is yet to be achieved. Immunization coverage is facing serious challenges in Pakistan. There are certain reasons for this low coverage:
- Inadequate infrastructure: surveys have shown that vaccinating teams are not fully equipped with sufficient vaccines and cold chains (Cold chains for vaccines is a system of storing and transporting vaccines at low temperatures to maintain their effectiveness before use). Vaccination centers are also situated in far-flung areas. Vaccinators are also not provided with transport facilities such as motorcycles, bicycles etc. The number of vaccinators is not sufficient. There are also reports of short supply of vaccines in Balochistan.
- Lack of private sector involvement: immunization of all the children across Pakistan is too huge a task to be achieved by the government alone. So private sector institutions should be taken on board for the accomplishment of immunization goals set by the EPI.
- Lack of awareness and education: Knowledge, attitudes and practices of parents and patients contribute to the success or failure of immunization programme. Low literacy rate in the rural and remote areas is the major cause of this lack of knowledge and awareness. Parents sometimes refuse to vaccinate their child due to possible side effects of vaccine such as rash and fever which pose no danger to the child.
- Lack of serious policy implementation: Currently, the National Expanded Programme on Immunization has been housed within the Ministry of Inter-provincial Coordination at the federal level. According to the national policy, there should be a number of health centers for immunization, but this number is not sufficient to cover the population. There are 6000 EPI centers; approximately one for about 27000 population. There are also lapses in keeping and validating records of immunization programmes. Sometimes, policies are influenced politically and the influence is more prevalent at the time of hiring of staff for EPI programmes. The Millennium Development Goals are not focused upon during policy making. Pakistan’s health and immunization indicators are lagging significantly behind regional countries’. Although Pakistan has made progress towards meeting MDG4 and MDG5 targets, progress has been insufficient and uneven and targets are unlikely to be met.
- Lack of motivation of EPI staff: It has been observed that service structure and salaries of vaccinators and other EPI staff are not sufficient. Many of the team members don’t continue their jobs due to a great deal of dissatisfaction over the incentives and allowances offered. “I was only once given a bicycle allowance in my 20 years of service”, a male vaccinator divulged. A women vaccinator, talking about the service structure, mentioned, “I was appointed in grade 5 and I am still serving in the same position for the last 20 years. I think that I will retire at the same”. Apart from this, in-service training for routine immunization staff is not planned. Regular EPI budget from the government does not allocate funds for continuing education and in-service training. This factor is a big challenge for routine immunization.
- Role of lady health workers: Lady Health workers and female vaccinators are a key to reaching women and children in rural and remote areas where health care facilities are not in an easy access. In KPK and Balochistan, there is an extreme shortage of female vaccinators due to strict practice of purdah (veil) within this region. Male vaccinators are also unable to access households to administer vaccines.
- Role of doctors and pediatricians: Doctors and pediatricians can also play a role in making routine immunization (RI) successful by educating their patients about the RI. It has been observed that doctors do not show any requisite interest in vaccination programmes. They don’t refer eligible children to the EPI centers.
- Role of political leaders and parliamentarians: Political representatives of an area can play a vital role in making Routine Immunization (RI) successful. Unfortunately, very little has been done on the part of local representatives in this regard.
- Effect of NIDs on routine immunization: During national immunization days (NIDs), most of the vaccinators and EPI staff remain busy in polio vaccination campaign. It may have detrimental effect on Routine Immunization.
The government has to take it seriously to improve the existing infrastructure. A good deal of attention has to be paid to the regular training of EPI staff and vaccinators. A specific monitoring system should be launched to ensure the quality and proper storage of vaccines. The performance of teams in relevant areas should also be monitored and a well-organized record should be maintained for future. Although much work needs to be done in the field for full coverage of children, there remains a promising ray of light in the form of a united effort where the private sector joins hands with the public sector in this lifesaving drive. If the two sectors can join hands and implement workable strategies towards Routine Immunization, it is certain that the dream of a vaccine preventable disease free Pakistan will come true.
By: Sadia Irfan