Post on 26-May-2015
description
Expanded Programme on Immunization Poverty and Social Impact Analysis
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Dr. Vaqar AhmedSustainable Development Policy Institute
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• Objectives• Situation Analysis• Literature Review and Gaps• Methodology • Results• Policy Recommendations• Open Discussion
Outline
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• 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
Objectives
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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
Consensus of Political Community
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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)
Characteristics of the Poor
- Inadequate service utilization, unhealthy sanitary and dietary practices etc
Poor Health Outcomes
- Ill health- Malnutrition- High fertility
Diminished Income
- Loss of wages- Costs of health care- Greater vulnerability to catastrophic illness
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Health is WealthHealth & Poverty Linkages
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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Determinants of Health Sector Outcomes
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Determinants of Health Sector OutcomesHouseholds
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Determinants of Health Sector OutcomesCommunities
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Determinants of Health Sector OutcomesHealth Services
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Determinants of Health Sector OutcomesGovernment
Related LiteratureHealth, Poverty & Space
Health &
Immunization
Economic Geography
Poverty &
Socio-economic Inequalities
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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 Health Journal, No. (11):745-752.
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Existing Literature EPI in PakistanRandomized 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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Gaps in the Literature1. 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 have not been identified
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PSIA—Methodology
Methods
Quantitative
Descriptive Analysis
Micro/Spatial Econometric Estimations
Social Impact Analysis
Benefit & Incidence Analysis
Qualitative
Stake holder Analysis Participatory
Techniques
Focus Group Discussions
Key Informant Interviews
Institutional Analysis
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SWOT Analysis of EPI ProgramStrengths
Commitment of political leadershipUnderstanding and priority in civil/field operationsA network of manpower and cold chainSanctioned reach in the farthest areasConsensus on fighting preventable diseasesReinforcement through NIDs
Opportunities 18th Amendment empowering provincesWillingness of international community to help Commitment of future funds/budgetWillingness of communities to help operationsPrivate sector’s willingness and ability to help
WeaknessesNo regular monitoring, evaluation and feedbackHeterogeneous service capacity across provincesLapses in budgetary releasesPoor synergies with other health sectorNIDs hindering routine immunizationNon-customized public awareness campaignsWeak grievance redressal system
ThreatsLack of accountability frameworkNatural disasters, conflicts and IDPsNorms preventing accessMissing birth records, lack of population censusLack of motivation and incentives for ground staffLacunas in vaccines stock management
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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
Institutional Analysis
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• 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
Institutional Analysis
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Budgetary Considerations
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-110
100
200
300
400
500
600
700
800
Requirements as per PC-1AllocationsReleasesExpenditureRs
. Mill
ion
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• Punjab– Scale Issues
• Sindh– Manpower/HR Issues
• Khyber Pakhtunkhwa– Access Issues
• Balochistan – HR & Access Issues
Service Delivery Analysis
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Household level AnalysisDistrict-wise Distribution of Respondents (%)
AbbotabadPeshawar
MardanBannu
GawadarQuettaDaddu
RohriKarachiLarkanaLahore
GujranawalaLayyah
Bhakkar
5 10 1533
66
410
77
65
99
1312
Percentage
Dis
tric
ts
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District-wise Immunization Position (%)
Karachi
Larka
na
Lahore
Gujranawala
Layy
ah
Bhakkar
Abbotabad
Peshawar
Mard
anBannu
Gawadar
Quetta
DadduRohri
83 7888
78 80 76
96 91 93
74
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74 73
52
17 2212
22 20 24
4 9 7
26
69
26 27
48
Fully Immunized (%) Partially Immunized (%)
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Were the Vaccinator’s Visits Regular?(Response Shown in Percentage )
88
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yes no
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Are You Aware of Govt’s EPI Initiatives?
78%
22%
yesno
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Does Immunization Prevent Disease?
53%47%
yes Don't Know
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Do You Endorse Initiatives Under EPI?
yes no Indifferent0
10
20
30
40
50
60
70
80
90
82.6
1.1
16.4
perc
enta
ge
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What is your most reliable source of Information on EPI? - Percentage
Radio, tv, newspaper
Public Banner, Local mosque,
NG
O
LHW
, Imm
unization team, local
awareness Cam
paign
All17.8 21.1
53.9
7.3
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Number of Estimated Lives Saved
19781981
19841987
19901993
19961999
20022005
20080
2000
4000
6000
8000
10000
12000
14000
16000
Rural UrbanTotalN
umbe
rs
The total number of incremental lives added as a consequence of EPI activities is around 0.3 million. Out of which around 0.19 million belong to rural Pakistan.
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Number of Workers Added to Labour Force
19781981
19841987
19901993
19961999
20022005
20082011
0
2000
4000
6000
8000
10000
12000
14000
RuralUrbanTotalN
umbe
rs
Since 1993 a total of 0.15 million incremental workers have joined the labour force owing to EPI activities post-1978
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Addition to Gross Domestic Production
19781981
19841987
19901993
19961999
20022005
20082011
0
200
400
600
800
1000
1200
1400
RuralUrbanTotal
Rs. M
illio
n at
Cur
rent
Pri
ces
The incremental lives saved under EPI activities contributed Rs. 11 billion (in 1993-94 prices) towards overall GDP and led to 8 percentage point decline in poverty on average over the decade of 2000s.
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• 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
Policy Recommendations