Expanded Programme on Immunization Poverty and Social Impact Analysis

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Dr. Vaqar AhmedSustainable Development Policy Institute

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• Objectives• Situation Analysis• Literature Review and Gaps• Methodology • Results• Policy Recommendations• Open Discussion

Outline

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• Review the social and poverty impacts of EPI• Analyze intended and unintended consequences of EPI on the welfare

of different groups• Elaborate the health as well as non-health factors adding to or

detracting from the targeted impact of EPI• Recommend new policies and changes to existing policies• Assess the possible impact of man-made and natural disasters• Evaluate if there are any significant differences in scope and

effectiveness of the program in urban and rural context• Put forward concrete recommendations to improve the program and

maximize its impact• Explore the value of Poverty and Social Impact Analysis (PSIA) in

analyzing policy choices

Objectives

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In order to equate the chances of every newborn child; let us take a simple step. Let us treat child immunization and primary education as a birth right of that child – a right to survive and a right to be educated. Let us persuade national governments and the international community to issue birth right vouchers to every new born child that guarantees at least these two investments in their future. The total cost will be modest – hardly three billion dollars a year – but it will provide a new social contract for our future generations, and it will certainly create a compassionate society.

– The former Finance Minister of Pakistan Dr. Mahbub ul Haq

Consensus of Political Community

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A National Emergency

• “Pakistan is now reporting more (polio) cases than

the combined total cases of the other three endemic countries: Nigeria, India, and Afghanistan.”

(2-10-11, Centre for Excellence in Molecular Biology, Lahore)

• “…what was disturbing was that polio cases were being reported from areas not directly affected by conflict or floods.”

(Elias Durry, Senior Coordinator, WHO’s Polio Eradication effort in Pakistan)

Characteristics of the Poor

- Inadequate service utilization, unhealthy sanitary and dietary practices etc

Poor Health Outcomes

- Ill health- Malnutrition- High fertility

Diminished Income

- Loss of wages- Costs of health care- Greater vulnerability to catastrophic illness

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Health is WealthHealth & Poverty Linkages

Caused by:- Lack of knowledge- Poverty in community: Social norms, weak institutions & infrastructure- Poor health provision : lack of access & inputs, low quality- Exclusion from health finance system

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Determinants of Health Sector Outcomes

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Determinants of Health Sector OutcomesHouseholds

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Determinants of Health Sector OutcomesCommunities

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Determinants of Health Sector OutcomesHealth Services

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Determinants of Health Sector OutcomesGovernment

Related LiteratureHealth, Poverty & Space

Health &

Immunization

Economic Geography

Poverty &

Socio-economic Inequalities

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Existing Literature on the EPI in Pakistan

•Ahmed, R et al (2011), Availability of Expanded Programme of Immunization services provided to children in a rural Pakistani village, JPMA Vol(61): 4. •Siddiqui et al (2011), Assessment of EPI (Expanded program of immunization) vaccine coverage in a peri-urban area, JPMA Vol (57).•Ahmed, H (2010), Immunization in Pakistan, PILDAT briefing paper No(37).•Siddiqui et al (2010), Mothers’ knowledge about EPI and its relation with age-appropriate vaccination of infants in peri-urban Karachi, JPMA, Vol(60): 11.•Maringo, Nawab.K et al, (2008), Is Expanded Programme on Immunization Doing Enough? Viewpoint of Health workers and Managers in Sindh, Pakistan, JPMA Vol 58 (2).•Hong, R & Banta, J.E (2005), Effects of extra immunization efforts on routine immunization at district level in Pakistan, East Mediterranean Health Journal, No. (11):745-752.

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Existing Literature EPI in PakistanRandomized Controlled Trial (RCT)

•Usman, H.R., Kristensen, S., Rahber, Hossein. M., Vermund, S.H., Habib, F and Chamot, E (2010), “ Determinants of third dose of DPT completion among children who received DTPI at EPI’s rural immunization centres in Pakistan: A cohort study,” Tropical Medicine and International Health, Vol 15 (1): 140-147

•Usman, H.R., Akhtar, S.H., & Jehan, I (2009), “Redesigned immunization card and center-based education to reduce childhood immunization dropouts in urban Pakistan : A randomized controlled trial” Vaccine (27): 467-472

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Gaps in the Literature1. Only specific areas have been investigated, an evaluation of regional

differences in the impact of EPI is missing

2. The impact of floods/terrorism has not been investigated

3. An evaluation of the political and cultural factors on the effectiveness of the EPI

4. Studies are mostly qualitative or descriptive and lack empirical analysis

5. Lack of recommendations to existing EPI related policies in order to maximize the impact of the EP on the poorest regions, poorest

households, women & children

6. Actions required to implement the recommendations keeping socio-economic, cultural & institutional factors in account have not been identified

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PSIA—Methodology

Methods

Quantitative

Descriptive Analysis

Micro/Spatial Econometric Estimations

Social Impact Analysis

Benefit & Incidence Analysis

Qualitative

Stake holder Analysis Participatory

Techniques

Focus Group Discussions

Key Informant Interviews

Institutional Analysis

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SWOT Analysis of EPI ProgramStrengths

Commitment of political leadershipUnderstanding and priority in civil/field operationsA network of manpower and cold chainSanctioned reach in the farthest areasConsensus on fighting preventable diseasesReinforcement through NIDs

Opportunities 18th Amendment empowering provincesWillingness of international community to help Commitment of future funds/budgetWillingness of communities to help operationsPrivate sector’s willingness and ability to help

WeaknessesNo regular monitoring, evaluation and feedbackHeterogeneous service capacity across provincesLapses in budgetary releasesPoor synergies with other health sectorNIDs hindering routine immunizationNon-customized public awareness campaignsWeak grievance redressal system

ThreatsLack of accountability frameworkNatural disasters, conflicts and IDPsNorms preventing accessMissing birth records, lack of population censusLack of motivation and incentives for ground staffLacunas in vaccines stock management

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Fragmentation–Prime Minister’s Secretariat• Inter-provincial Committee

–Ministry of Inter-provincial Coordination• Federal EPI Office

–Planning Commission• Health Section

–Provincial Offices• Human resource• Vaccine delivery

Institutional Analysis

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• Coverage targets– Need for population census– Data coming from provinces not validated

• Media coverage– Excessively for polio

• Non-customized Monitoring & Evaluation• Burden of NIDs• Natural disasters and migration• Need for greater synergy with other vertical

programs

Institutional Analysis

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Budgetary Considerations

2003-04

2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-110

100

200

300

400

500

600

700

800

Requirements as per PC-1AllocationsReleasesExpenditureRs

. Mill

ion

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• Punjab– Scale Issues

• Sindh– Manpower/HR Issues

• Khyber Pakhtunkhwa– Access Issues

• Balochistan – HR & Access Issues

Service Delivery Analysis

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Household level AnalysisDistrict-wise Distribution of Respondents (%)

AbbotabadPeshawar

MardanBannu

GawadarQuettaDaddu

RohriKarachiLarkanaLahore

GujranawalaLayyah

Bhakkar

5 10 1533

66

410

77

65

99

1312

Percentage

Dis

tric

ts

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District-wise Immunization Position (%)

Karachi

Larka

na

Lahore

Gujranawala

Layy

ah

Bhakkar

Abbotabad

Peshawar

Mard

anBannu

Gawadar

Quetta

DadduRohri

83 7888

78 80 76

96 91 93

74

31

74 73

52

17 2212

22 20 24

4 9 7

26

69

26 27

48

Fully Immunized (%) Partially Immunized (%)

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Were the Vaccinator’s Visits Regular?(Response Shown in Percentage )

88

12

yes no

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Are You Aware of Govt’s EPI Initiatives?

78%

22%

yesno

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Does Immunization Prevent Disease?

53%47%

yes Don't Know

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Do You Endorse Initiatives Under EPI?

yes no Indifferent0

10

20

30

40

50

60

70

80

90

82.6

1.1

16.4

perc

enta

ge

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What is your most reliable source of Information on EPI? - Percentage

Radio, tv, newspaper

Public Banner, Local mosque,

NG

O

LHW

, Imm

unization team, local

awareness Cam

paign

All17.8 21.1

53.9

7.3

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Number of Estimated Lives Saved

19781981

19841987

19901993

19961999

20022005

20080

2000

4000

6000

8000

10000

12000

14000

16000

Rural UrbanTotalN

umbe

rs

The total number of incremental lives added as a consequence of EPI activities is around 0.3 million. Out of which around 0.19 million belong to rural Pakistan.

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Number of Workers Added to Labour Force

19781981

19841987

19901993

19961999

20022005

20082011

0

2000

4000

6000

8000

10000

12000

14000

RuralUrbanTotalN

umbe

rs

Since 1993 a total of 0.15 million incremental workers have joined the labour force owing to EPI activities post-1978

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Addition to Gross Domestic Production

19781981

19841987

19901993

19961999

20022005

20082011

0

200

400

600

800

1000

1200

1400

RuralUrbanTotal

Rs. M

illio

n at

Cur

rent

Pri

ces

The incremental lives saved under EPI activities contributed Rs. 11 billion (in 1993-94 prices) towards overall GDP and led to 8 percentage point decline in poverty on average over the decade of 2000s.

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• Reorganizing EPI Governance at Federal Level• Establishment of Planning Cells in Provincial EPI Offices• Monitoring & Evaluation Cells in Provincial EPI Offices• Linking EPI with Disaster Management Framework• Grievance Redressal System• Vaccine Stock Management• Rectifying Incentives Structure• Linking EPI with Nadra Offices• Restructuring and Customizing Public Awareness Campaigns• Building Synergies with other Health Sector Initiatives• Public Private Sector Working Group on EPI• Special EPI Working Groups on Hard Areas• Annual Mandatory Trainings & Ideas Exchange Opportunities

Policy Recommendations

Thank You

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vaqar@sdpi.org