Abstract
Karachi, the largest city in Pakistan, having high population growth and a complex health care environment, has highest density of unimmunized (zero dose) and under-immunized children. The main reasons of low immunization coverage in Karachi were lack of governance and accountability in a duplicative and fragmented health management structure, weak and inequitable immunization services, and lack of demand and trust among people for immunization services. The Expanded Programme on Immunization (EPI), Ministry of Health (MOH) in Sindh Province spearheaded a structured and collaborative process to develop strategies for addressing inequity in immunization services towards achieving Universal Immunization Coverage (UIC) in Karachi. The process included a situation analysis with gathering quantitative and qualitative information on the root causes of zero-dose and inequity of the immunization services. The strategies and interventions were developed with multi-layer input and feedback of the stakeholders and partners, and focusing primarily to address gaps in three program areas: governance, leadership and accountability; immunization service delivery; and building demand and trust among the people. The interventions were further prioritized for high-risk areas; identified based on maximum number zero-dose children, presence of large slum areas, measles outbreak and on-going circulation of wild poliovirus. Finally, costing for the Roadmap activities was done through consultation with partners and aligning domestic and external (donor) resources. In this paper, we have highlighted the unique process the Sindh Government undertook in collaboration with the stakeholders and partners to develop strategies and interventions for addressing inequity in urban immunization services in Karachi towards achieving Universal Immunization Coverage (UIC). Similar processes can be adapted, as a potential model, for developing strategies to achieve universal health coverage in the cities of Pakistan and in other countries.
Highlights
Pakistan is urbanizing rapidly, with about 36.4% of the national population currently residing in urban areas [1]
The strategies and interventions were developed with multi-layer input and feedback of the stakeholders and partners, and focusing primarily to address gaps in three program areas: governance, leadership and accountability; immunization service delivery; and building demand and trust among the people
The public health system in Karachi could not keep pace with the rapidly growing urban population, and people living in unauthorized urban settlement areas are excluded from immunization services resulting in inequity of immunization coverage
Summary
With about 36.4% of the national population currently residing in urban areas [1]. The capital of Sindh province, has a population of over 16 million, making it the largest city in Pakistan [3]. The public health system in Karachi could not keep pace with the rapidly growing urban population, and people living in unauthorized urban settlement areas are excluded from immunization services resulting in inequity of immunization coverage. The Pakistan Demographic and Health Survey (PDHS 2017-18) found full immunization coverage with basic vaccines in the urban areas of the Sindh province at 66%, with major inequity in coverage between the richest (80%) and poorest (38%) people in both rural and urban populations [6]. In order to achieve UIC the Sindh EPI initiated a collaborative process involving stakeholders and partners to develop strategies for a Roadmap for improving equitable access of immunization services to all population of Karachi regardless of where they live
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