Health system barriers and levers in implementation of the Expanded Program on Immunization (EPI) in Pakistan: an evidence informed situation analysis

Vaccine Trends in Pakistan: A Review of Immunization Challenges and Setbacks Prompted by Inadequate Disaster Management

Pakistan bears an incredible burden of vaccine-preventable diseases, and efforts to improve widespread immunization have been hindered by inadequate public health management following disasters and other health emergencies. Through a brief review of Pakistan's health system, an understanding of routine immunization challenges is sought based on the organizational changes made to the planning and delivery of immunization activities. Further, recent immunization trends of measles, polio, and tuberculosis are examined in correspondence to health emergencies prompted by climate change and the COVID-19 pandemic. The national public health response to each disease is discussed, and insight is given to how the devolution of Pakistan's health system may have influenced the severity of each emergency. Focus is given to the potential immunization challenges and how they may impact future initiatives for the control of vaccine-preventable diseases. Although incidence rates suggest increased cases of certain vaccine-preventable diseases and disruptions of immunization activities following recent disasters, further studies may need to be conducted to establish a stronger understanding of the immunization trends noted within this review.

Understanding multilevel barriers to childhood vaccination uptake among Internally Displaced Populations (IDPs) in Mogadishu, Somalia: a qualitative study

BACKGROUND

Disparities in vaccination coverage exist in Somalia with Internally Displaced Persons (IDPs) being among the groups with the lowest coverage. We implemented an adapted Participatory Learning and Action (PLA) intervention, which focused on routine vaccinations among displaced populations living in Mogadishu IDP camps. The intervention was successful in improving maternal knowledge and vaccination coverage but unsuccessful in improving timely vaccination. We conducted a qualitative study to understand this result and analyze the multi-level barriers to routine childhood immunization uptake.

METHOD

In this qualitative study we used observation data from 40 PLA group discussions with female caregivers and purposively sampled nine vaccination service providers and six policy makers for interview. We also reviewed national-level vaccine policy documents and assessed the quality of health facilities in the study area. We used the socioecological framework to structure our analysis and analyzed the data in NVivo.

RESULTS

The barriers to childhood vaccination among IDPs at the individual level were fear due to lack of knowledge, mistrust of vaccines, concerns about side effects and misinformation; opportunity costs; and costs of transportation. At the interpersonal level, family members played an important role as did the extent of decision-making autonomy. Community factors such as cultural practices, gender roles, and household evictions influenced vaccination. Organizational issues at health facilities such as waiting times, vaccine stock-outs, distance to the facility, language differences, and hesitancy of health workers to open multi-dose vials affected vaccination. At the policy level, confusion about the eligible age for routine vaccination and age restrictions for catch-up vaccination and certain antigens such as BCG were important barriers.

CONCLUSION

Complex and interrelated factors affect childhood vaccination uptake among IDPs in Somalia. Interventions that address multiple barriers simultaneously will have the greatest impact given the complex nature of vulnerabilities in this population. There is a need to strengthen the health system and connect it with existing community structures to increase demand for services. Our research highlights the importance of formative research before implementing interventions. Further research on the integration of health service strengthening with PLA to improve childhood vaccination among IDPs is recommended.

TRIAL REGISTRATION NUMBER

ISRCTN-83,172,390. Date of registration: 03/08/2021.

Unveiling and addressing implementation barriers of vaccination communication strategy: Perspectives from government officials at national and provincial levels

Communication strategy is one of the support of primary health care (PHC) that can address demand-side barriers and socio-cultural factors to promote better services. Conversely, communication strategies have not been a distinct emphasis of vaccination research in the country until now. Therefore, this study aimed to find the elements that influence the provision of vaccination communication in Pakistan. Twenty-two semi-structured interviews with key stakeholders in vaccine communication were conducted using qualitative methodologies (Jan 2022-March 2022). The interviews revolved around factors affecting the implementation of communication. Interviews were transcribed and analyzed using thematic analysis. By using the SURE framework, numerous factors that affect vaccination communication were identified under three major themes such as organizational-level, constitutional, and community-level factors. Five subthemes marked the organizational-level factors such as constrained budget, infrastructure deficits, inconsistent comprehensive strategy, health workforce, and inadequate training. Two subthemes are derived regarding constitutional and community-level factors, respectively, such as governance and leadership, health communication interventions not a policymaker's priority, community perceptions and practices, and formal partnership lacking between national and local stakeholders. Additionally, employment of established communication committees, improved money allocation, engagement of traditional and religious institutions, and political backing were identified as solutions for improvement. Communication activities are an important part of immunization programs in order to increase vaccination coverage. To be able to execute communication interventions more successfully, national and provincial stakeholders must work together to identify the elements that affect vaccine provision. Additional rigorous implementation studies could aid in the development of clearer knowledge of the system-wide constraints obstructing the program's efficiency.

Factors affecting vaccination demand in Indonesia: a secondary analysis and multimethods national assessment

OBJECTIVES

Vaccine hesitancy remains a major barrier to immunisation coverage worldwide. We explored influence of hesitancy on coverage and factors contributing to vaccine uptake during a national measles-rubella (MR) campaign in Indonesia.

DESIGN

Secondary analyses of qualitative and quantitative data sets from existing cross-sectional studies conducted during and around the campaign.

METHODS

Quantitative data used in this assessment included daily coverage reports generated by health workers, district risk profiles that indicate precampaign immunisation programme performance, and reports of campaign cessation due to vaccine hesitancy. We used t-test and χ² tests for associations. The qualitative assessment employed three parallel national and regional studies. Deductive thematic analysis examined factors for acceptance among caregivers, health providers and programme managers.

RESULTS

Coverage data were reported from 6462 health facilities across 395 districts from 1 August to 31 December 2018. The average district coverage was 73%, with wide variation between districts (2%-100%). One-third of districts fell below 70% coverage thresholds. Sixty-two of 395 (16%) districts paused the campaign due to hesitancy. Coverage among districts that never paused campaign activities due to hesitancy was significantly higher than rates for districts ever-pausing the campaign (81% vs 42%; p<0.001). Precampaign adequacy of district immunisation programmes did not explain coverage gaps (p=0.210). Qualitative analysis identified acceptance enablers including using digital health monitoring and feedback systems, increasing caregiver knowledge and awareness, making immunisation social norm, effective cross-sectoral collaboration, conducive service environment and positive experiences for mothers and children. Barriers included misinformation diffusion on social media, halal-haram issues, lack of healthcare provider knowledge, negative family influences and traditions, previous poor experiences and misinformation on adverse events.

CONCLUSION

Barriers to vaccine uptake contributed to coverage gaps during national MR campaign in Indonesia. A range of supply-related and demand-related strategies were identified to address hesitancy contributors. Advancing a portfolio of tailored multilevel interventions will be critical to enhance vaccine acceptance.

Assessment of vaccination service delivery and quality: a cross-sectional survey of over 1300 health facilities from 29 districts in Sindh, Pakistan conducted between 2017-18

Background

Routine childhood immunization coverage in Pakistan remains sub-par, in part, due to suboptimal utilization of existing vaccination services. Quality of vaccine delivery can affect both supply and demand for immunization, but data for immunization center quality in Pakistan is sparse and in Sindh province in Southern Pakistan, no comprehensive health facility assessment has ever been conducted at a provincial level. We assessed health facilities, specifically immunization centers, and their associated health workers throughout the province to summarize quality of immunization centers. 

Methods

An exhaustive list of health facilities obtained from Sindh’s provincial government was included in our analysis, comprising a total of 1396 public, private, and public-private health facilities. We adapted a health facility and health worker assessment survey developed by BASICS and EPI-Sindh to record indicators pertaining to health facility infrastructure, processes and human resources. Using expert panel ranking, we developed critical criteria (the presence of a cold box/refrigerator, vaccinator and vaccination equipment at the immunization center) to indicate the bare minimum items required by immunization centers to vaccinate children. We also categorized other infrastructure, process, and human resource items to determine high, low and moderate function requirements to ascertain quality. We evaluated presence of critical criteria, calculated scores for high, moderate and low function requirements, and displayed frequencies of infrastructure, process and human resource indicators for all immunization centers across Sindh. We analyzed results at the division level and utilized a two-sample independent clustered t-test to test differences in average function requirement scores between facilities that met critical criteria and those that did not.

Results

Out of the 1396 health facilities assessed across Sindh province from October 2017 to January 2018, 1236 (88.5%) were operational while 1209 (86.6%) offered vaccination services (immunization centers). Only 793 (65.6%; 793/1209) immunization centers met the critical criteria of having all the following items: vaccinator, a cold box or refrigerator and vaccine supplies. Of the 416 (34.4%; 416/1209) immunization centers that did not meet the critical criteria, most of the centers did not have a cold box or refrigerator (28.3%; 342/1209), followed by lack of vaccines (19.9%; 240/1209), and a vaccinator (13.0%; 157/1209). Of the 2153 healthcare workers interviewed, 1875 (87.1%) were vaccinators, of which 1745 (81.0%; 1745/2153) were male, and had an average of 12.4 years of schooling. A total of 1805 (96.3%; 1805/1875), 1655 (88.3%; 1655/1875) and 1387 (74.0%; 1387/1875) of the vaccinators were trained in vaccination, cold chain and inventory management respectively.

Conclusion

One out of three immunization centers in Sindh lack the critical components essential for quality vaccination services. While the majority of health workers (>80%) were trained on vaccination and cold chain management, the proportion trained on inventory management was comparatively low. Our findings therefore suggest that suboptimal immunization center quality is partly due to inadequate infrastructure and inefficient processes contributed to an extent, by low levels of inventory management training among vaccinators. Our study presents critical research findings with high-impact policy implications for identifying and addressing gaps to improve vaccination uptake within a low-middle income country setting.

Investments for effective functionality of health systems towards Universal Health Coverage in Africa: A scoping review

The health challenges in Africa underscore the importance of effectively investing in health systems. Unfortunately, there is no information on systems investments adequate for an effective functional health system. We aimed to address this by conducting a scoping review of existing evidence following the Joanna Briggs Institute Manual for Evidence Synthesis and preregistered with the Open Science Framework (https://osf.io/bvg4z). We included any empirical research describing interventions that contributed to the functionality of health systems in Africa or any low-income or lower-middle-income regions. We searched Web of Science, MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, and ERIC from their inception, and hand-searched other relevant sources. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. We identified 554 unique reports describing 575 interventions, of which 495 reported evidence of effectiveness. Most interventions were undertaken in Africa (80.9%), covered multiple elements of health systems (median: 3), and focused on service delivery (77.4%) and health workforce (65.6%). Effective interventions contributed to improving single (35.6%) or multiple (64.4%) capacities of health systems: access to essential services (75.6%), quality of care (70.5%), demand for essential services (38.6%), or health systems resilience (13.5%). For example, telemedicine models which covered software (technologies) and hardware (health workers) elements were used as a strategy to address issues of access to essential services. We inventoried these effective interventions for improving health systems functionality in Africa. Further analyses could deepen understanding of how such interventions differ in their incorporation of evidence for potential scale across African countries.

Severity of COVID-19 in bacillus Calmette-Guérin vaccinated population

Purpose

Considering the cross-protection reported for bacillus Calmette-Guérin (BCG) vaccination on viral respiratory infections, it has been proposed that it could reduce the severity of coronavirus disease 2019 (COVID-19). The objective of the current study is to investigate the association between the severity of COVID-19 with prior BCG vaccination in adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Materials and Methods

Adult patients (18 years or above) with positive SARS-CoV-2 polymerase chain reaction admitted in July 2020 were included in this cross-sectional study. Patients were classified into non-severe, severe, and critical diseases. History of prior BCG vaccination and the presence of a BCG vaccination scar were recorded.

Results

Out of 103 patients, 64 patients with prior history of BCG vaccinations were compared with 39 patients without BCG vaccination in childhood. The median age was 55 years and 64 years in BCG vaccinated & non-BCG vaccinated patients (p-value=0.002). There was male predominance in both groups and frequent comorbid illnesses were hypertension and diabetes mellitus. Severe COVID-19 was found in 91 patients (88.3%) followed by non-severe disease and critical diseases i.e., 7 (6.8%) and 5 (4.9%) patients, respectively. No association of prior BCG vaccination with disease severity of COVID-19 was found in this study and mortality was 8.7%. Out of nine patients who expired only 2 (22.2%) had a prior history of BCG vaccination (p-value=0.01). Secondary infections were present in 26 patients and the majority had pneumonia.

Conclusion

The BCG vaccine has no impact on the severity of COVID-19 but could have a protective role with a low mortality rate in already infected patients.

Unveiling and addressing implementation barriers to routine immunization in the peri-urban slums of Karachi, Pakistan: a mixed-methods study

BACKGROUND

Great disparities in immunization coverage exist in Pakistan between urban and rural areas. However, coverage estimates for large peri-urban slums in Sindh are largely unknown and implementation challenges remain unexplored. This study explores key supply- and demand-side immunization barriers in peri-urban slums, as well as strategies to address them. It also assesses immunization coverage in the target slums.

METHODS

Conducted in four peri-urban slums in Karachi, this mixed-methods study consists of a baseline cross-sectional coverage survey of a representative sample of 840 caregivers of children aged 12-23 months, and 155 in-depth interviews (IDIs) through purposive sampling of respondents (caregivers, community influencers and immunization staff). After identifying the barriers, a further six IDIs were then conducted with immunization policy-makers and policy influencers to determine strategies to address these barriers, resulting in the development of an original validated implementation framework for immunization in peri-urban slums. A thematic analysis approach was applied to qualitative data.

RESULTS

The survey revealed 49% of children were fully vaccinated, 43% were partially vaccinated and 8% were unvaccinated. Demand-side immunization barriers included household barriers, lack of knowledge and awareness, misconceptions and fears regarding vaccines and social and religious barriers. Supply-side barriers included underperformance of staff, inefficient utilization of funds, unreliable immunization and household data and interference of polio campaigns with immunization. The implementation framework's policy recommendations to address these barriers include: (1) improved human resource management; (2) staff training on counselling; (3) re-allocation of funds towards incentives, outreach, salaries and infrastructure; (4) a digital platform integrating birth registry and vaccination tracking systems for monitoring and reporting by frontline staff; (5) use of digital platform for immunization targets and generating dose reminders; and (6) mutual sharing of resources and data between the immunization, Lady Health Worker and polio programmes for improved coverage.

CONCLUSIONS

The implementation framework is underpinned by the study of uncharted immunization barriers in complex peri-urban slums, and can be used by implementers in Pakistan and other developing countries to improve immunization programmes in limited-resource settings, with possible application at a larger scale. In particular, a digital platform integrating vaccination tracking and birth registry data can be expanded for nationwide use.

Critical Review of Data Analytics Techniques used in the Expanded Program on Immunization (EPI)

BACKGROUND

Immunization is a significant public health intervention to reduce child mortality and morbidity. However, its coverage, in spite of free accessibility, is still very low in developing countries. One of the primary reasons for this low coverage is the lack of analysis and proper utilization of immunization data at various healthcare facilities.

PURPOSE

In this paper, the existing machine learning-based data analytics techniques have been reviewed critically to highlight the gaps where this high potential data could be exploited in a meaningful manner.

RESULTS

It has been revealed from our review that the existing approaches use data analytics techniques without considering the complete complexity of Expanded Program on Immunization which includes the maintenance of cold chain systems, proper distribution of vaccine and quality of data captured at various healthcare facilities. Moreover, in developing countries, there is no centralized data repository where all data related to immunization is being gathered to perform analytics at various levels of granularities.

CONCLUSION

We believe that the existing non-centralized immunization data with the right set of machine learning and Artificial Intelligence-based techniques will not only improve the vaccination coverage but will also help in predicting the future trends and patterns of its coverage in different geographical locations.

Immunisation program reviews in East and Southern Africa (2012-2018): key lessons

Introduction

the World Health Organisation (WHO) recommends that countries conduct comprehensive national immunisation program reviews regularly to help them identify systems wide-barriers or gaps and monitor performance against the set targets.

Methods

we reviewed reports from the latest national immunisation program reviews conducted in the 20 countries in the sub-region in the course of 2012-2018. We generated descriptive analysis of the findings across the sub-region.

Results

the 20 program reviews included field observations to the subnational levels as well as interviews with program staff and stakeholders. At the time of the reviews, only 11 countries had functional National Immunisation Technical Advisory Groups. Operational funding was inadequate in half of the countries. The reviews documented the cancellation of outreach services, supportive supervision visits and maintenance of cold chain equipment due to the lack of fuel or operational funding. Immunisation programs in 10 countries had major human resource gaps. Vaccine stock management tools were not effectively used in 10 countries, and stock out of vaccines and supplies was documented in 9 countries during the review. The full components of the RED strategy were implemented in only 3 of the 20 countries. Twelve countries reported challenges with the availability and accuracy of target populations. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews.

Conclusion

the reviews demonstrated challenges in various aspects of the programs in different countries. The implementation of the review recommendations should be built into the annual program plans, as well as into coasted multi-year plans, in order to address the gaps and helps the program to attain the set targets. With the rapid evolution of the scope and complexity of the immunisation programs in recent years, countries should invest their efforts in building the capacity of their human resources as well as updating their logistics and data systems.

Immunisation program reviews in East and Southern Africa: 2012-2018; key lessons

Introduction

World Health Organisation (WHO) recommends that countries conduct comprehensive national immunisation programme reviews regularly to help them identify systems wide-barriers or gaps and monitor performance against the set targets.

Methods

we reviewed reports from the latest national immunisation program reviews conducted in the 20 countries in the subregion in the course of 2012-2018. We generated descriptive analysis of the findings across the subregion.

Results

the 20 program reviews included field observations to the subnational levels as well as interviews with program staff and stakeholders. At the time of the reviews, only 11 countries had functional National Immunisation Technical Advisory Groups. Operational funding was inadequate in half of the countries. The reviews documented the cancellation of outreach services, supportive supervision visits and maintenance of cold chain equipment due to the lack of fuel or operational funding. Immunisation programs in 10 countries had major human resource gaps. Vaccine stock management tools were not effectively used in 10 countries, and stockout of vaccines and supplies was documented in 9 countries during the review. The full components of the Reaching Every District (RED) Strategy were implemented in only 3 of the 20 countries. Twelve countries reported challenges with the availability and accuracy of target populations. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews.

Conclusion

the reviews demonstrated challenges in various aspects of the programs in different countries. The implementation of the review recommendations should be built into the annual program plans, as well as into costed multi-year plans, in order to address the gaps and helps the program to attain the set targets. With the rapid evolution of the scope and complexity of the immunisation programs in recent years, countries should invest their efforts in building the capacity of their human resources as well as updating their logistics and data systems.

An Artificial Intelligence-Based, Personalized Smartphone App to Improve Childhood Immunization Coverage and Timelines Among Children in Pakistan: Protocol for a Randomized Controlled Trial

BACKGROUND

The immunization uptake rates in Pakistan are much lower than desired. Major reasons include lack of awareness, parental forgetfulness regarding schedules, and misinformation regarding vaccines. In light of the COVID-19 pandemic and distancing measures, routine childhood immunization (RCI) coverage has been adversely affected, as caregivers avoid tertiary care hospitals or primary health centers. Innovative and cost-effective measures must be taken to understand and deal with the issue of low immunization rates. However, only a few smartphone-based interventions have been carried out in low- and middle-income countries (LMICs) to improve RCI.

OBJECTIVE

The primary objectives of this study are to evaluate whether a personalized mobile app can improve children's on-time visits at 10 and 14 weeks of age for RCI as compared with standard care and to determine whether an artificial intelligence model can be incorporated into the app. Secondary objectives are to determine the perceptions and attitudes of caregivers regarding childhood vaccinations and to understand the factors that might influence the effect of a mobile phone-based app on vaccination improvement.

METHODS

A mixed methods randomized controlled trial was designed with intervention and control arms. The study will be conducted at the Aga Khan University Hospital vaccination center. Caregivers of newborns or infants visiting the center for their children's 6-week vaccination will be recruited. The intervention arm will have access to a smartphone app with text, voice, video, and pictorial messages regarding RCI. This app will be developed based on the findings of the pretrial qualitative component of the study, in addition to no-show study findings, which will explore caregivers' perceptions about RCI and a mobile phone-based app in improving RCI coverage.

RESULTS

Pretrial qualitative in-depth interviews were conducted in February 2020. Enrollment of study participants for the randomized controlled trial is in process. Study exit interviews will be conducted at the 14-week immunization visits, provided the caregivers visit the immunization facility at that time, or over the phone when the children are 18 weeks of age.

CONCLUSIONS

This study will generate useful insights into the feasibility, acceptability, and usability of an Android-based smartphone app for improving RCI in Pakistan and in LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04449107; https://clinicaltrials.gov/ct2/show/NCT04449107.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/22996.

Strategies to Improve Coverage of Typhoid Conjugate Vaccine (TCV) Immunization Campaign in Karachi, Pakistan

The emergence and spread of extensively drug-resistant (XDR) typhoid in Karachi, Pakistan led to an outbreak response in Lyari Town, Karachi utilizing a mass immunization campaign with typhoid conjugate vaccine (TCV), Typbar TCV®. The mass immunization campaign, targeted Lyari Town, Karachi, one of the worst affected towns during the XDR typhoid outbreak. Here we describe the strategies used to improve acceptance and coverage of Typbar TCV in Lyari Town, Karachi. The mass immunization campaign with Typbar TCV was started as a school- and hospital-based vaccination campaign targeting children between the age of 6 months to 15 years old. A dose of 0.5 mL Typbar TCV was administered intramuscularly. A mobile vaccination campaign was added to cope with high absenteeism and non-response from parents in schools and to cover children out of school. Different strategies were found to be effective in increasing the vaccination coverage and in tackling vaccine hesitancy. Community engagement was the most successful strategy to overcome refusals and helped to gain trust in the newly introduced vaccine. Community announcements and playing typhoid jingles helped to increase awareness regarding the ongoing typhoid outbreak. Mop-up activity in schools was helpful in increasing coverage. Networking with locally active groups, clubs and community workers were found to be the key factors in decreasing refusals.

Electronic immunization information systems: a case report of lessons learned from implementation in Pakistan

Pakistan ranks third globally in the number of unvaccinated and under-vaccinated children, and Sindh province has one of the lowest vaccination rates in the country. Electronic census-based immunization information systems have the potential to bolster traditional immunization service delivery mechanisms, but literature has largely not focused on implementation at scale in Pakistan. This is a case report of technical support provided to the Sindh Department of Health/Expanded Program on Immunization (DOH/EPI) from 2015 to 2017 to strengthen routine immunization (RI). The program developed an immunization information system used by district health officers to register and track individual immunization status, improve vaccine logistics, and generate more accurate population estimates and vaccination targets. District immunization officers (DIOs) assisted their district health management teams and supervisors to use registration and service data stored in the immunization information system database to prepare microplans, monitor catchment area performance, and solve problems. Civil society partners registered 830,610 children (aged 0 to 23 months) and 348,315 pregnant women in 28,565 villages over an 18-month intensive intervention period. By the end of this period, 65% of all registered women had been vaccinated with two or more doses of the tetanus toxoid vaccine (compared to 26% at baseline); Penta 3 vaccination coverage had increased from 27% to 64%; and 52% of the registered children (aged 0 to 23 months) were fully immunized (compared to 18% at baseline). The immunization information system helped district managers identify and focus limited resources on high-risk populations; reminded families and health providers when vaccinations were due or missed; assisted managers in monitoring vaccination coverage, vaccinator performance, and vaccine stocks; and encouraged local problem solving to improve RI performance. The Government of Sindh demonstrated a commitment to RI based on the program's results, which bode well to future enhancements and scale up.

System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan

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.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0452-z) contains supplementary material, which is available to authorized users.