Expanded Programme on Immunization: Poverty & Social Impact Analysis

1. Expanded Programme on Immunization
Poverty and Social Impact Analysis
Dr. Vaqar Ahmed
Sustainable Development Policy Institute
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2. Outline
• Objectives
• Situation Analysis
• Literature Review and Gaps
• Methodology
• Results
• Policy Recommendations
• Open Discussion
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3. 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
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4. Consensus of Political Community
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
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5. 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)
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6. 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
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7. Determinants of Health Sector Outcomes
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8. Determinants of Health Sector Outcomes
Households
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9. Determinants of Health Sector Outcomes
Communities
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10. Determinants of Health Sector Outcomes
Health Services
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11. Determinants of Health Sector Outcomes
Government
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12. Related Literature
Health, Poverty & Space
Health
&
Immunization
Poverty
& Economic
Socio-economic Geography
Inequalities

13. 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
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Health Journal, No. (11):745-752.

14. 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 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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15. Gaps in the Literature
1. 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
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have not been identified

16. PSIA—Methodology
Descriptive Analysis
Micro/Spatial Econometric Estimations
Quantitative
Social Impact Analysis
Benefit & Incidence Analysis
Methods
Focus Group
Stake holder Discussions
Analysis Participatory
Techniques Key Informant
Qualitative Interviews
Institutional
Analysis
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17. SWOT Analysis of EPI Program
Strengths Opportunities
Commitment of political leadership 18th Amendment empowering provinces
Understanding and priority in civil/field Willingness of international community to
operations help
A network of manpower and cold chain Commitment of future funds/budget
Sanctioned reach in the farthest areas Willingness of communities to help
Consensus on fighting preventable diseases operations
Reinforcement through NIDs Private sector’s willingness and ability to help
Weaknesses Threats
No regular monitoring, evaluation and Lack of accountability framework
feedback Natural disasters, conflicts and IDPs
Heterogeneous service capacity across Norms preventing access
provinces Missing birth records, lack of population
Lapses in budgetary releases census
Poor synergies with other health sector Lack of motivation and incentives for ground
NIDs hindering routine immunization staff
Non-customized public awareness campaigns Lacunas in vaccines stock management
Weak grievance redressal system 17

18. Institutional Analysis
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
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19. 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
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20. Budgetary Considerations
800
700
600
Requirements as per
500
Rs. Million
PC-1
400 Allocations
300
Releases
200
100 Expenditure
0
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21. Service Delivery Analysis
• Punjab
– Scale Issues
• Sindh
– Manpower/HR Issues
• Khyber Pakhtunkhwa
– Access Issues
• Balochistan
– HR & Access Issues
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22. Household level Analysis
District-wise Distribution of Respondents (%)
Bhakkar 12
Layyah 13
Gujranawala 9
Lahore 9
Larkana 5
Karachi 6
Districts
Rohri 7
Daddu 7
Quetta 10
Gawadar 4
Bannu 6
Mardan 6
Peshawar 3
Abbotabad 3
2 4 6 8 10 12 14
Percentage
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23. District-wise Immunization Position (%)
96 91 93
88
83 78 78 80 76 74 74 73
69
5248
31 27
22 22 24 26 26
17 20
12 9
4 7
Fully Immunized (%) Partially Immunized (%)
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24. Were the Vaccinator’s Visits Regular?
(Response Shown in Percentage )
12
88
yes no
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25. Are You Aware of Govt’s EPI Initiatives?
0%
22%
yes
no
78%
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26. Does Immunization Prevent Disease?
47%
53%
yes Don't Know
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27. 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
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28. 28
What 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

29. 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
2006
The total number of incremental lives added as a consequence of EPI activities is
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around 0.3 million. Out of which around 0.19 million belong to rural Pakistan.

30. 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
2010
Since 1993 a total of 0.15 million incremental workers have joined the
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labour force owing to EPI activities post-1978

31. 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
2010
The incremental lives saved under EPI activities contributed Rs. 11
billion (in 1993-94 prices) towards overall GDP and led to 8 percentage
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point decline in poverty on average over the decade of 2000s.

32. 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

33. Thank You
vaqar@sdpi.org
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