My visit to Pakistan has been invigorating. There is no substitute to seeing things on the ground, and what I have seen looks impressive. In the span of just one year, the country has covered substantial ground in terms of coordination between federal and provincial governments. This is quite a turnaround from one year ago, when in the aftermath of sudden devolution, there were persisting difficulties with regard to strategic direction and management of immunisation program. Attacks on vaccinators were dominating the headlines and immunisation seemed to bein disarray with mounting worries.
More than 1000 children in Pakistan die every day before celebrating their fifth birthday – unnecessarily as most of these deaths could be prevented with simple interventions of which vaccines are the most important. More than half of these children die of vaccine preventable diseases such as pneumonia, diarrhoea, measles and meningitis. Yet, vaccination coverage in Pakistan remains lower than the global average and many other much poorer countries. 13 lakh children in the country remain deprived of the full course of even the most basic vaccines while many do not receive any vaccines at all. There are disturbing disparities within the country and within the provinces and districts. So while more children in Punjab receive vaccination overall, urban slums continue to present a challenge. Balochistan, on the other hand, has more than 70 out of every 100 children missing full course of the most basic vaccines with some districts having virtually no coverage. Similarly a large number of children in Sindh remain deprived of life saving vaccines.
These disparities are unacceptable. Children born to rich and educated parents benefit from the protection that vaccines offer. On the other hand, the poor and the marginalized whose children are at higher risk of death, disease and disability because of a multitude of disadvantages including poor access to sanitation, water, nutrition and hygiene are unable to access life saving vaccines because of systemic failure. This situation must change and within Pakistan, Punjab is showing the way.
Given that Punjab is the wealthiest of Pakistan’s provinces that may come as no great surprise. However, what is less obviousis that aggregate statistics at the provincial level can mask disturbing sub-provincial inequities. Within Punjab, there are areaswhere progress is slow and entire communities may be missing out on the benefits of life-saving vaccines.Unfortunately there is little realisation that low childhood immunisation rates can have a deep and long-term negative impact on local economies, while high vaccine coverage rates can have the opposite effect.
According to research published last month in the journal Health Affairs, for every dollar invested in childhood immunisation there is on average a return of US$ 16 in saved healthcare costs, lost wages and productivity due to illness and a return of $44 in broader economic gains.So when immunisation gaps start to appear across a nation, there is a very real danger they may help exacerbate wealth disparities that already exist. Unless we find ways to close these gaps and address inequities, other provinces will fall even further behind.
In Pakistan such gaps appear to be vast, and increasingly so. Overall immunisation rates have stagnated since 2011, with coverage of three shots of diphtheria-tetanus-pertussis(DTP) stalling at around 73% in 2014. When you break this down by province the regional inequities are immediately apparent; the latest national figures suggest that coverage in Sindh is 38.6% and in Baluchistan as low as 27.1%. Meanwhile in Punjab coverage is as high as 76.3% and rising. In fact, according to some figures, DTP3– coverage in Punjab has increased by 18% in the last year alone.
To understand the economic ramifications of this, consider how these two very different coverage rates can affect the finances of an individual family and the broader economy. In areas of low coverage, an unvaccinated infant is potentially more likely to get sick. Besides the additional healthcare or treatment costs this can entail, the ability of her parents to work will also be impacted. Together, these factors conspire to place more economic pressure on families with the potential push them into poverty.
However, it follows that if we can prevent illness, we not only eliminate the burden of healthcare costs but also improve earning capacity of parents. This means that they will have a greater disposable income to feed back into the economy. Meanwhile the infant will have a fairer chance of growing into a healthy child, able to attend school with better learning outcomes and eventually become a more productive member of society. All this translate into substantial economic gains for the local community, the region and ultimately Pakistan. According to the Health Affairs study, from 2011 to 2020 childhood immunisation in 94 low- and middle-income countries is set to return US$ 1.43 trillion in economic benefits, including nearly $600 billion in more direct benefits, such as reduction in hospital costs etc.It is, in every sense, an investment. It is also an investment in prevention which as we all know is better than cure. Illness has an economic dimension but it also causes human suffering the cost of which is hard to quantify in dollars.
The case of Punjab in Pakistan is an inspiring one. It embodies the power of political leadership- when leaders decide to act, communities flourish. Systems start to reboot and impediments begin to diminish. Punjab also exemplifies the strength of seamless partnerships- greater cooperation between federal and provincial governments and other actors has led to improvements in immunisation services, with 500 more health centres fully functional, compared to a year ago. Recognising the importance to augment human resources, there has been good progress in dealing with staff shortages, with more community health workers and vaccinators recruited in the same period. Most importantly, there is focus on accountability – technology is being leveraged to get information in real time on actual delivery of immunisation services through the use of innovative solutions like the use of mobile phones to track vaccinators. Early indications suggest that leadership from the top and these otherinvestmentshave begun to yield dividends through increases in coverage.
Let us hope other provinces would emulate Punjab sooner than later. Gavi, the Vaccine Alliance, is committed to supporting Pakistan in its endeavors. Pakistan is the largest recipient of Gavi funds among 73 low-income countries and the total support by Gavi in terms of vaccines and health systems strengthening would touch nearly $ 1 billion. There is an exciting opportunity for Pakistan to catalyse this support to bring sharp focus on children in remote, hard to reach, poor settings, so that no child is left behind and each child is enabled to live and attain full potential through effective vaccination.
As the world ushers in the new Sustainable Development Goals with its central aspiration to leave no one behind, Pakistan must reach every child with the full range of life saving vaccines and lay the foundation for a strong Universal Health Coverage. Immunisation is the gateway to health and often the first service to reach communities. A strong immunisation programme would pave the way for broader strengthening of health care at primary level, the stepping stone to universal health coverage.