WHEN it comes to immunisation, Pakistan has two very different reputations. On the one hand it is known for its heroic Lady Health Workers (LHWs), the 100,000 women who have played a key part in trying to provide vital health services such as immunisation to some of Pakistan’s most marginalised people. Yet at the same time the savage attacks on these women for their role in promoting health has sent shockwaves throughout the world.

But as despicable and damaging as these attacks are, they are not the only threat to the delivery of vaccines to children in Pakistan. Through a lack of coordination and leadership, both the federal and provincial governments have created systemic problems that go to the very heart of Pakistan’s immunisation programme.

Unless these issues are addressed to ensure that vaccinators are in post and appropriately supported, and clinics open when mothers bring their children in for immunisation, the governments run the risk of undermining progress and ultimately failing Pakistan’s children.

Pakistan may not meet the MDG of reducing under-five mortality.

Despite hundreds of millions of dollars of investment, both from foreign donor organisations and government coffers, immunisation coverage rates remain worryingly low.

Since 1990, routine immunisation has risen from 35pc to a point where around half of Pakistan’s children will still not receive all of even the most basic vaccines. While this does mark an increase it falls significantly short of the 90pc laid out in the World Health Organisation’s Global Vaccination Action Plan and belies the true extent of coverage. Huge variations in coverage exist both geographically, with coverage virtually non-existent in some districts, and across gender. Girls in particular lose out.

All this should be cause for concern, because access to immunisation services is the bellwether of health services; it is usually a reliable indicator of whether other vital health services are reaching people.

Indeed, currently 400,000 children under-five now die every year in Pakistan from diseases, many of which could have been prevented with vaccines. What this means is that in terms of childhood mortality Pakistan is not only being eclipsed by its neighbours, like Bangladesh, it is now also highly unlikely to meet its Millennium Development Goal of reducing by two-thirds, between 1990 and 2015, under-five childhood mortality.

A big part of the problem is the way in which the devolution of health services has been handled. It has been three years since devolution and there is still lack of clarity of where responsibility ends at the federal level, and at which point the provincial government picks it up. This kind of unclear division of responsibilities is one reason why, shortly after a scheme was set up to provide salaries for the LHWs, it was suspended for two years.

At the federal level we need greater political commitment to maintain key strategic functions, to ensure that work carried out at the district level supports a national strategy.

For this to work, federal authorities need to continue being responsible for vaccine procurement and safety, national policy development and the handling of disease monitoring and evaluation of programmes as well as disease surveillance. This will enable the provinces and districts to focus on finding and implementing innovative solutions to improve access to vaccines, such as the use of smartphone technology to track vaccinations.

There also needs to be recognition of the inherent synergies that exist between polio eradication efforts and increasing routine immunisation coverage.

We all want to see the end to polio in Pakistan, but diverting resources away from routine immunisation is not the way to solve it. It is like trying to mend a leaky dam by pulling corks from one hole to fix another. And as Pakistan transitions away from oral polio vaccines to the injectable inactivated poliovirus vaccine (IPV) as a necessary part of the eradication strategy, the role that routine immunisation plays will become ever more prominent.

Global health organisations such as Gavi, the Vaccine Alliance, are here to support Pakistan on this journey. Between 2001 and 2020 we have committed more than $800 million to that end. Gavi and its partners, like WHO and Unicef, recognise that money alone won’t solve these challenges, but we also need to see that funds are being spent wisely and effectively, and for that we need to see change at both the federal and provincial levels.

Ultimately Pakistan’s children need champions to safeguard their futures. Such champions already exist at the district level in the form of the brave LHWs, the vaccinators and district managers. But if they are to continue their work and be successful in shifting public attitudes and reaching more children, then more champions are needed at every level of Pakistan’s immunisation programme working to remove these barriers to progress.

The writer is CEO of Gavi, the Vaccine Alliance.

Published in Dawn, February 20th, 2015

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