On Wednesday, February 19, 2020, The CPPG cordially invited Dr. Samia Waheed Altaf and Dr. Sameen A. Mohsin Ali to speak on “Understanding Pakistan’s Immunization Problem: A Transactional Approach. Dr. Samia Waheed Altaf, a physician and public health specialist. She was the Wilson Center’s 2007-08 Pakistan Scholar. She has also authored a book on Pakistan’s health system titled So much Aid, So Little Development: Stories from Pakistan (2011). Dr. Sameen Ali is an Assistant Professor in the Department of Humanities & Social Sciences at LUMS. She completed her Ph.D. in Politics from SOAS University of London in 2018.

In their presentation, the speakers explained that Pakistan has struggled with high childhood and infant mortality rates, limited resources, inadequate health and medical services, and poor scores on most socio-economic indicators. The child mortality rate in Pakistan is abysmal due to communicable diseases such as measles, pneumonia, and polio. They stated that these infectious diseases are one of the major contributors to under five child mortality rates. To combat deaths from vaccine-preventable diseases, the government proposed the Expanded Program on Immunization (EPI), which includes the Polio Eradication program, in the late 1980s. However the program has made snail pace progress.

Out of all the reasons for the failure of the program to achieve expected results, vaccine hesitancy is found as a crucial problem coupled with poor governance and administrative loopholes. They shed light on two aspects of public health provision about vaccinations. First, the processes of decision-making and policy implementation in the Punjab Department of Health. Second, the cultural, economic, and social context of Pakistan’s EPI.  They hypothesize that the reforms that the Punjab government has introduced in the health sector in general, and the EPI in particular, have been problematic. They conducted a pilot study research to provide local context to inform policy-making, in the district of Kasur with detailed household surveys, focus groups and review of health organization trainings. They found that, given Pakistan’s challenges and constraints, there are deficiencies on both the demand and supply side of vaccine services. Some of the reasons which affect the eradication of polio in supply side are political unrest, poor health infrastructure, and government negligence, lack of political will. Furthermore, the EPI is donor funded with funds being earmarked for very specific expenses (e.g equipment, training, vaccines) so it is very hard for the government to make its own policies with respect to immunization coverage. When the government will spend its own money on vaccinating children, it will have better control over how the vaccinations are given.

There is a wide range of obstacles to immunization, including religious, political and socioeconomic barriers. The researchers found that the mindset of people was a major factor impacting vaccination coverage. It has been shown that low parental – specifically, maternal – literacy and knowledge regarding vaccines and immunization schedules, poor socioeconomic status, and residence in rural areas all are attributable to whether or not a child is immunized. People have misconceptions about the polio vaccine such as ‘it causes sterility in children’, ‘it contains pig fat’ and ‘vaccines used in programme are sub-standard’. Moreover, Dr. Ali and Dr. Altaf criticized the poor training programs of vaccinators who are unable to answer basic, legitimate questions of parents such as why the vaccine is important? What kind of side effects will it have? Is the vaccine expired? And so on.

She emphasized when it comes to healthcare, Pakistan is lagging far behind even in the list of developing countries. In terms of vaccination programs to eradicate polio, most countries like Nigeria, Bangladesh, India have good vaccination programs even they have similar development bottlenecks like Pakistan. She talked about the strategy used in Washington D.C, where a set of incentives/penalties are built into the system so families ensure their children are vaccinated. For example, if students are not immunized, they cannot attend school, and if children are not attending school, their parents can be charged with criminal offence. As a result parents ensure timely immunization of their children.

In terms of recommendations, the speakers felt that immunization needed to be integrated to other primary healthcare services such as maternal care to increase coverage. Prevention needs to be prioritised, improvements in recruitment, remuneration, and training of vaccinators are necessary, the local governments need to be involved and there need to be focused health education programs in languages and formats geared towards the education level of the local population.