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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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
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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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
31
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
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.