Peer-reviewed article
System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan
Zaeem ul Haq, Babar Tasneem Shaikh, Nhan T Tran, Assad Hafeez, Abdul Ghaffar ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001Pakistan's Expanded Programme on Immunisation, established in 1978, faces significant challenges in delivering routine vaccinations to children despite high infant and child mortality from vaccine-preventable diseases. A qualitative study of 34 key stakeholders identified structural and implementation barriers including unclear service delivery models, insufficient staffing, inaccurate population data, logistical problems, budget constraints, security risks, and community vaccine hesitancy. The research reveals that immunisation challenges stem largely from interactions between the EPI programme and broader health system components, compounded by global polio eradication pressures and socio-political factors.
Key points
- Half of Pakistan's infant and child deaths are from vaccine-preventable diseases
- Immunisation rates remain chronically low with unsatisfactory on-time vaccination coverage
- Major barriers include lack of clarity on fixed vs. mobile vaccination delivery models, human resource scarcity, and absence of a dedicated EPI budget line
- Polio eradication efforts have created unintended consequences for routine immunisation programmes
- Community misconceptions about vaccines and security risks for outreach activities impede service delivery
Limitations
The study provides insights into stakeholder perceptions and system-level challenges but does not quantify immunisation coverage rates, measure the relative impact of different barriers, or test interventions to address identified problems. It focuses on policy and implementation perspectives rather than community or provider-level experiences.
Abstract
BACKGROUND: Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme's performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme's insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities. METHODS: We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO's six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes. RESULTS: The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines. CONCLUSIONS: The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals.