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Expanded Programme on Immunization: Poverty & Social Impact Analysis

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Expanded Programme on Immunization in Pakistan

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Expanded Programme on Immunization: Poverty & Social Impact Analysis

  1. 1. Expanded Programme on Immunization Poverty and Social Impact Analysis Dr. Vaqar Ahmed Sustainable Development Policy Institute 1
  2. 2. Outline• Objectives• Situation Analysis• Literature Review and Gaps• Methodology• Results• Policy Recommendations• Open Discussion 2
  3. 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 3
  4. 4. 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
  5. 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) 5
  6. 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 6
  7. 7. Determinants of Health Sector Outcomes 7
  8. 8. Determinants of Health Sector Outcomes Households 8
  9. 9. Determinants of Health Sector Outcomes Communities 9
  10. 10. Determinants of Health Sector Outcomes Health Services 10
  11. 11. Determinants of Health Sector Outcomes Government 11
  12. 12. Related Literature Health, Poverty & Space Health & Immunization Poverty & EconomicSocio-economic Geography Inequalities
  13. 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 13 Health Journal, No. (11):745-752.
  14. 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 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
  15. 15. 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
  16. 16. PSIA—Methodology Descriptive Analysis Micro/Spatial Econometric Estimations Quantitative Social Impact Analysis Benefit & Incidence AnalysisMethods Focus Group Stake holder Discussions Analysis Participatory Techniques Key Informant Qualitative Interviews Institutional Analysis 16
  17. 17. 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
  18. 18. 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
  19. 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 19
  20. 20. Budgetary Considerations 800 700 600 Requirements as per 500Rs. Million PC-1 400 Allocations 300 Releases 200 100 Expenditure 0 20
  21. 21. Service Delivery Analysis• Punjab – Scale Issues• Sindh – Manpower/HR Issues• Khyber Pakhtunkhwa – Access Issues• Balochistan – HR & Access Issues 21
  22. 22. Household level Analysis District-wise Distribution of Respondents (%) Bhakkar 12 Layyah 13 Gujranawala 9 Lahore 9 Larkana 5 Karachi 6Districts Rohri 7 Daddu 7 Quetta 10 Gawadar 4 Bannu 6 Mardan 6 Peshawar 3 Abbotabad 3 2 4 6 8 10 12 14 Percentage 22
  23. 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 (%) 23
  24. 24. Were the Vaccinator’s Visits Regular? (Response Shown in Percentage ) 12 88 yes no 24
  25. 25. Are You Aware of Govt’s EPI Initiatives? 0% 22% yes no 78% 25
  26. 26. Does Immunization Prevent Disease? 47% 53% yes Dont Know 26
  27. 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 27
  28. 28. 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
  29. 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 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.
  30. 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 2010Since 1993 a total of 0.15 million incremental workers have joined the 30labour force owing to EPI activities post-1978
  31. 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 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.
  32. 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. 33. Thank Youvaqar@sdpi.org 33

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