I must emphasize here, that most of the media coverage of EPI revolves around Polio coverage. A very simple online search of the EPI status in Pakistan lists pages that discuss polio.
First of all, there are certain characteristics that are typical to the poorer segments of society such asInadequate health service utilizationUnhealthy sanitary and dietary practices etcThat causes them to have poor health statuses: This can include a disease or an illness, malnutrition, and also includes high fertility rates amongst poor women.Poor health statuses naturally lead to diminished incomes as people are unable to actively participate in the labour force.There is loss of wagesThey get poorer due to the costs of their health care that they have to bearAnd they also get more vulnerable to terminal diseasesDiminished income, itself is caused by Lack of knowledge, poverty in the community, lack of access to health services etcand the cycle continues
Now once we have understood the health and poverty linkages, we need a conceptual framework that links the institutions that influence the health sector outcomes. This identification of the determinants and the linkages between them is extremely important for evaluating the social and poverty impacts of any heath program. This framework helps us to organize our analysis of the possible questions we need to answer for any health sector programme.
HOUEHOLDS:Households ‘produce’ health through the consumption of food, by adopting certain dietary and sanitary practices, their consumption of health damaging commodities such as cigarettes. None of these variables are fixed. While some take households adopt health health practices, other are careless and dont take care.No matter what poorer households do fall behind anyway, because they are unable to maintain proper nutrition levels. So basically analysing household behaviour is important so that we can determine what are the household factors that make the EPI a success or a failure.
COMMUNITY:The values and social norms of a community can play a big role in influencing household health decisions. Involving communities in a program increases the social accountability of any program.They can also exert ( a negative or a positive) influence on how the health service, the Epi in our case will be delivered. Therefore In the context of the EPI, we need to identify and analyze what kind of community institutions, social capital, local envoirnment and infrastructure can influence the EPI outcomes.
HEALTH SERVICESIs a broad concept that involves various institutions. First is the question of accessibility to the health service by the people. How easy is it, how far is it? How is the infrastructure etcSecond we have to see whether there is a sufficient supply of the health service, how is its qualityAnd whether people have access to some sort of public or private health financing mechanism etcOTHER SECTORS :What is the role of transport, infrastructure, water, sanitation sectors in influencing health outcomes.
Finally we have the Public Sector or the policies and actions of the GovernmentIntuitively there is a large number of institutions come under the government , all of which can influence the households, communities, health finance and Health services. Once we have a framework, we need to prioritize . We can not focus on everything at the same time. And this is precisely the stage at which qualitative analysis which involves stakeholders comes in handy.
For a detailed study on the EPI, 3 types of literature have to utilized.
To our knowledge so far since I have just started reading on the EPI in Pakistan, there is a limited amount of published literature on the EPI.Most of them are Region specificUtilize descriptive statistics or a simple logit regression analysisThe PILDAT briefing paper by H Ahmed (2010) is the only online entry that one can access when we want to consider legal and political factors that can influence the EPI.We have information that several donors have conducted evaluations of EPI program in Pakistan over the last few years, something that Dr. TayyebMasud from World Bank has pointed out in his reply to our stakeholder’s questionnaire. We will need your maximum support in gathering these evaluations and the reports on this subject.
Another very popular technique that is being utilized across the world to carry out programme evaluations is that of Randomized Controlled Trials.In this approach before a policy is implemented, one group of people is treated with the policy and another group of people is not so that the differences between the treated and non treated groups can be investigated. So for example the first paper has drawn comparisons between two groups of children one which received the third dose of DPT and another one that did not.
From the limited literature that we have studied in detail, the follow gaps have been identifiedI would like repeat that we will need your maximum support in gathering the existing evaluations and reports that are not available on line and can be of use in our analysis.
Now our PSIA methodology like any other comprehensive impact assessment report will utilize both: quantitative and qualitative techniques.Descriptive analysis of EPI data obtained from secondary sources. This will include data/indicators on inputs, outputs and outcomes. By carrying out an Econometric analysis of the EPI: we will be able to emprically determine the influence of household factors on immunization coverage and rates, or tow hat extent does immunization have a poverty reducing role in Pakistan. Social impact analysis will take account of impact of EPI intervention on: lifestyle, cultural indicators, community-level behaviors and pure-health impacts.Benefit assessment amongst other things will focus on the targeting efficacy, cost effectiveness, coverage and follow up.
Sindh: political recruitment
Expanded Programme on Immunization: Poverty & Social Impact Analysis
Expanded Programme on Immunization Poverty and Social Impact Analysis Dr. Vaqar Ahmed Sustainable Development Policy Institute 1
Outline• Objectives• Situation Analysis• Literature Review and Gaps• Methodology• Results• Policy Recommendations• Open Discussion 2
Objectives• 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 3
Consensus of Political CommunityIn order to equate the chances of every newborn child; let us takea simple step. Let us treat child immunization and primaryeducation as a birth right of that child – a right to survive and aright to be educated. Let us persuade national governments andthe international community to issue birth right vouchers toevery new born child that guarantees at least these twoinvestments in their future. The total cost will be modest – hardlythree billion dollars a year – but it will provide a new socialcontract for our future generations, and it will certainly create acompassionate society. – The former Finance Minister of Pakistan Dr. Mahbub ul Haq 4
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) 5
Health is Wealth Health & Poverty Linkages Characteristics Poor Health Diminished of the Poor Outcomes Income - Loss of wages - Inadequate service - Ill health - Costs of health care utilization, unhealthy - Malnutrition sanitary and dietary - Greater practices etc - High fertility vulnerability to catastrophic illness 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 6
Determinants of Health Sector Outcomes Households 8
Determinants of Health Sector Outcomes Communities 9
Determinants of Health Sector Outcomes Health Services 10
Determinants of Health Sector Outcomes Government 11
Related Literature Health, Poverty & Space Health & Immunization Poverty & EconomicSocio-economic Geography Inequalities
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 13 Health Journal, No. (11):745-752.
Existing Literature EPI in Pakistan Randomized Controlled Trial (RCT)• Usman, H.R., Kristensen, S., Rahber, Hossein.M., Vermund, S.H., Habib, F and Chamot, E (2010), “ Determinants ofthird dose of DPT completion among children who received DTPI at EPI’srural immunization centres in Pakistan: A cohort study,” TropicalMedicine and International Health, Vol 15 (1): 140-147• Usman, H.R., Akhtar, S.H., & Jehan, I (2009), “Redesignedimmunization card and center-based education to reduce childhoodimmunization dropouts in urban Pakistan : A randomized controlledtrial” Vaccine (27): 467-472 14
Gaps in the Literature1. Only specific areas have been investigated, an evaluation of regional differences in the impact of EPI is missing2. The impact of floods/terrorism has not been investigated3. An evaluation of the political and cultural factors on the effectiveness of the EPI4. Studies are mostly qualitative or descriptive and lack empirical analysis5. Lack of recommendations to existing EPI related policies in order to maximize the impact of the EP on the poorest regions, poorest households, women & children6. Actions required to implement the recommendations keeping socio-economic, cultural & institutional factors in account 15 have not been identified
SWOT Analysis of EPI Program Strengths OpportunitiesCommitment of political leadership 18th Amendment empowering provincesUnderstanding and priority in civil/field Willingness of international community tooperations helpA network of manpower and cold chain Commitment of future funds/budgetSanctioned reach in the farthest areas Willingness of communities to helpConsensus on fighting preventable diseases operationsReinforcement through NIDs Private sector’s willingness and ability to help Weaknesses ThreatsNo regular monitoring, evaluation and Lack of accountability frameworkfeedback Natural disasters, conflicts and IDPsHeterogeneous service capacity across Norms preventing accessprovinces Missing birth records, lack of populationLapses in budgetary releases censusPoor synergies with other health sector Lack of motivation and incentives for groundNIDs hindering routine immunization staffNon-customized public awareness campaigns Lacunas in vaccines stock managementWeak grievance redressal system 17
Institutional AnalysisFragmentation – 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 18
Institutional Analysis• 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 19
Budgetary Considerations 800 700 600 Requirements as per 500Rs. Million PC-1 400 Allocations 300 Releases 200 100 Expenditure 0 20
Were the Vaccinator’s Visits Regular? (Response Shown in Percentage ) 12 88 yes no 24
Are You Aware of Govt’s EPI Initiatives? 0% 22% yes no 78% 25
Does Immunization Prevent Disease? 47% 53% yes Dont Know 26
Do You Endorse Initiatives Under EPI? 90 80 82.6 70 60 percentage 50 40 30 20 10 16.4 1.1 0 yes no Indifferent 27
28What is your most reliable source of Information on EPI? - Percentage 7.3 All LHW, Immunization 53.9 team, local awareness Campaign 21.1 Public Banner, Local 17.8 mosque, NGO Radio, tv, newspaper
Number of Estimated Lives Saved 16000 14000 12000 10000 Numbers 8000 Rural Urban 6000 Total 4000 2000 0 1990 2008 1978 1980 1982 1984 1986 1988 1992 1994 1996 1998 2000 2002 2004 2006The total number of incremental lives added as a consequence of EPI activities is 29around 0.3 million. Out of which around 0.19 million belong to rural Pakistan.
Number of Workers Added to Labour Force 14000 12000 10000 Numbers 8000 Rural 6000 Urban 4000 Total 2000 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010Since 1993 a total of 0.15 million incremental workers have joined the 30labour force owing to EPI activities post-1978
Addition to Gross Domestic Production 1400 1200 Rs. Million at Current Prices 1000 800 Rural 600 Urban Total 400 200 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010The incremental lives saved under EPI activities contributed Rs. 11billion (in 1993-94 prices) towards overall GDP and led to 8 percentage 31point decline in poverty on average over the decade of 2000s.
Policy Recommendations• 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 32