Spotlight on missed children
Pakistan closed 2011 with one of the worst performing years fighting polio in more than a decade. With 191 cases, it has more than doubled its 2010 caseload – already a 60% increase from 2009.
Balochistan and Sindh are the two epicenters of the virus, with about 72% of the country’s cases either reported in these provinces, or genetically linked to them. It is no surprise that polio persists in the localized areas of sectarian violence, urban conflict and pervasive poverty still common there.
Poor management in FATA and Balochistan contributes to these provinces consistently missing the largest proportion of children, though mismanagement is reported from across the country. Following new guidelines stipulated in the President’s newly revised Emergency Action Plan, campaigns in several areas of Quetta were postponed due to a lack of preparation. In areas with persistent poor performance, it is proposed that future campaign implementation be outsourced to NGOs.
December results have not yet shown the progress anticipated following the intense pressure to implement the new Emergency Action Plan, but regular field reports indicate that management is improving. The potential for progress through the new plan, with the leadership shown by the Prime Minister’s newly appointed focal point for Polio, is promising.
Why are we missing children?
Children unavailable, and teams not visiting households are the two largest reasons for missed children (see Figure PAK1), each accounting for almost half of missed children nationally.
In December, 61% of children in Sindh were missed because they were not available when the teams visit, according to Independent Monitoring. Extrapolating this data against Sindh’s target population for the December campaign, this could mean up to 513,070 children were missed for this reason. Yet little information exists on where these children are, and how vaccination and communication strategies could be better designed to reach them. UNICEF is developing its own monitoring system to shed light on this and additional in-depth analyses that may help improve coverage. However, without routine analysis of data, operational and communication plans are unable to tackle the specific reasons children are missed.
Vaccinators as young as eight years old are routinely employed in areas such as Balochistan, leading to higher proportions of children missed due to ‘refusal’ and ‘no team’ in this province. Employing underage vaccinators has been a common strategy of districtlevel managers who can pocket money saved from children’s reduced salaries and lower transportation costs. While refusals in Balochistan are due to a number of reasons, parents’ lack of confidence in service delivery is a significant concern.
In other areas, gender and language also present barriers. Deploying female teams is generally the preferred approach so that they may engage effectively and openly with mothers.
However, a female vaccination team was beaten in Pishin in October, highlighting the importance of tailoring servicedelivery and communication strategies for each unique local context.
Understanding the magnitude of refusal
Refusals in Pakistan have fallen substantially over the year, particularly in the chronically resistant areas of Quetta Block in Balochistan (see Figure PAK2).
In Balochistan, the percentage of missed children due to refusal has fallen from 23% in January to 7% in December. In the 3 high risk districts of Quetta Block, rates have plunged even more dramatically in the same time period. Refusals in Quetta have gone from 42% to 7%, and in Pishin, from 76% to 36%, though Pishin’s data quality is questionable. In October, for example, independent monitoring could not take place due to the unavailability of qualified monitors.
Despite the decline shown from monitoring data, administrative records show an increasing trend in absolute numbers of refusal in Pishin and Quetta, the latter rising consistently between March and December, from 1,592 to 3,193 cases of documented refusals. As mentioned throughout this report, there are quality concerns with both independent monitoring and administrative data. However, until at least one credible data source exists, it is difficult to understand whether refusals have increased or decreased.
Refusals in Karachi declined throughout the year, but have risen steeply in December to 26% of children missed. Karachi’s reasons for refusal are very different from elsewhere, and are largely due to middle and upper class caregivers refusing public vaccination in favor of private service.
However, the towns of Gadap, Baldia, Saddar and Gulshan e Iqbal, have historically been strongholds of refusals rooted in religious and cultural reasons. Here, social mobilizers hired through NGOs, as well as the new COMNet were showing substantial improvements until December, when rates jumped to all-time highs. This needs to be carefully monitored to determine if it is a one-off event or a growing trend.
Engaging the critics
For the past year, Pakistan has launched an increasingly aggressive campaign to reach out to leaders of political and religious parties opposing polio campaigns. Over the last quarter in Pishin and Killa Abdullah, for example, conferences were held with multiple political parties prior to SIAs with a plea to increase their collective involvement and ownership over the programme. In particular, they were asked to encourage their communities to participate as vaccinators, in order to create more locally appropriate teams.
In the last two campaigns, political parties in these two districts provided vehicles for mobile announcements, and over 100 volunteers to serve as extra team members to address the refusals.
Fatwas in support of OPV have been obtained in Killa-Abdulla and Quetta from renowned religious scholars, which have been successfully used during campaigns to help convince parents that OPV is safe.
Representing a considerable breakthrough for the programme, following years of opposition by many Jamiat Ulemai Islam (JUI) clerics, the highly influential leader of the Party - Maulana Fazal ur Rehman, threw his public support behind the programme. His renewed endorsement came after months of discussions with the partners, culminating in a meeting with high-level officials in October.
Since the Maulana issued a letter to his Ameers, JUI members have been actively involved in campaign preparation and implementation. The Maulana himself administered vaccine to children in Quetta in November, marking his first public engagement in support of polio eradication in some time.
District-level religious leaders of JUI now disseminate polio message through mosque announcements and Friday sermons. They also nominate a contact person in each Union Council who can serve as liaisons with COMNet Union Council Officers. Together, the pair facilitates activities between JUI members and communities.
Similar tactics are being replicated in Karachi. In the Pashto-dominated towns and high-risk areas in the city, Jamia Binoria Town is one of the most highly influential branches of the Deoband Sect. With the help of Government and COMNet staff in the field, Mufti Naeem, one of the branch’s leaders, issued a fatwa in support of OPV. The partners have also released a video of Mufti Naeem vaccinating a child in Gulshane- Iqbal (Karachi), which will be used for localized PSAs and IEC material in subsequent campaigns.
UNICEF is planning to replicate NGO partnerships from Sindh and FATA to Balochistan in order to ensure maximum resources are working together to reduce refusals.