QUETTA: The air hits you like an ice-cold knife as you step into the freezer room in Quetta’s Expanded Programme on Immunization (EPI) office building.

A prohibited area which is under strict guard, the vault-like room (kept at minus 24 degrees Centigrade) is stacked from floor to ceiling with shelves upon shelves of thousands of neatly stacked sealed boxes of vaccines worth millions of rupees.

This vault is inside a huge whitewashed warehouse that also houses four cold rooms, which maintain a temperature of 4.6 degrees Centigrade, where more vaccines are stored.

All the cold rooms, including one run on solar energy, are digitally connected to record the temperatures.

“There will be no stock-outs, that’s for sure,” beamed Dr Ishaq Panezai, deputy provincial coordinator of the EPI, Balochistan, pointing to the vaccines and adding: “We have a one-year stock of vaccines.” He as well as officials at the federal EPI can keep a tab on the temperature setting sitting in the comfort of their homes.

Pakistan launched the programme in 1978 with the aim to save children aged 0-11 months against vaccine preventable deaths (caused by diseases like tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type B, pneumonia and measles) and pregnant women against tetanus. At present, seven vaccines are being administered in Balochistan.

But ensuring a cold chain to protect the vaccines’ potency and availability of enough vaccines for the 0.31 million babies is probably the easier task the EPI is trying to perform in the province.

Political appointments of district health officers are among major bottlenecks

On World Immunisation Week (April 24-30), all eyes in Pakistan seem to be focused on Balochistan where the dismal routine immunisation coverage stood at 16.4 per cent according to the Pakistan Demographic and Health Survey of 2012-13, but which, Dr Panezai said, has improved to 51pc as per the latest Pakistan Social And Living Standards Measurement of 2014-2015. The districts of Dera Bugti, Bolan, Loralai, Pishin and Sibi have shown persistently low coverage.

The province is at pains to remove the bottlenecks that are giving its vaccination programme a bad name. These include insufficient funding, delay in release of funds, weak and ineffective monitoring, reporting and surveillance system and unreliable data — population and target figures — coupled with weak supervision and management. In some areas the programme has made progress while in others work remains to be done to improve its efficacy.

Among the issues the EPI is trying to address is power failure. While Balochistan continues to reel from long hours of outages, sometimes stretching up to 20 hours, the problem has been resolved at the EPI centres to a large extent by procuring generators and keeping a budget for running them on diesel.

With just 480 EPI centres, and 914 vaccinators, in the 688 union councils of Balochistan, the programme aims at expanding its coverage by establishing 300 new centres and increasing its army of vaccinators to 1,600 by the end of 2018.

In the meantime, the vaccinators are being provided with some 350 motorcycles by June to ensure they continue with the work and reach areas which remain uncovered. “Along with motorcycles, we have ensured they get 20 litres of petrol and Rs1,000 per month for repair and maintenance,” said Dr Panezai.

Furthermore, to ensure that each child is vaccinated, a new software, called E-Vacc, has been introduced through the help of the Punjab Information Technology Board. At a pilot phase in 11 of the 30 districts of Balochistan, vaccinators have been provided android phones to register each child with a photo and the name of the vaccine given. “We are going through some teething pains but funds have been released for the rest of the 19 districts,” Dr Panezai told Dawn. He said another way they can monitor vaccination is to ask all centres at UCs to return empty vials before they are given the next supply of vaccines.

While Sindh is no better at 29 per cent rate of coverage, Islamabad with 74pc, followed at close heels by Punjab (66pc), add a silver lining to the national EPI campaign. Even Khyber Pakhtunkhwa at 53pc has scored better.

However, there seems to be a new focus on Balochistan for the first time.

From Rs2 million in 2012-13, the Public Sector Development Programme allocation for the fiscal 2016-2017 for Balochistan has been raised to a whopping Rs772.50 million.

The challenges the province, with a population of nearly 9.1 million, faces are very different from any other. It has a scattered population and a difficult terrain with many areas security compromised, so we cannot have a one-size-fits-all strategy for it.

For the moment, said Dr Panezai, parents needed to be motivated to bring their children to the EPI centres. “Because the polio campaign has been taken door to door, parents think the other vaccinations should also be brought to their doorstep. We need to somehow communicate to them that these vials cannot be taken out from EPI centres without an arduous cold chain in place as the vaccines lose their efficacy if temperature is not maintained,” he said. “When a vaccine vial is opened, it is used for anywhere between five to 20 children.” He urged the media to play a more proactive role in communicating this and the fact that vaccines were administered free of cost, to people. “It would cost Rs 32,000 to fully immunize your kid otherwise,” he said.

With so much emphasis on monitoring, evaluation and accountability now that systems are in place, Dr Panezai agreed that there should now be no excuse for anyone from the government side not to play its part in vaccinating the babies.

And yet, in hushed whispers many others say that until the appointment of district health officers on a political basis is stopped and the officials are held accountable, the coverage will fail to improve. And this applies to Sindh as well.

Published in Dawn, April 29th, 2017