The devastating floods that submerged one-third of Pakistan in 2022 have severely disrupted the country’s vaccination programme, leaving millions of children at risk of preventable diseases.

The floods severely damaged health infrastructure, causing overall immunization coverage in the country to drop to 64% in 2022, from a national average of 74% in 2020, according to a new national survey conducted by the World Bank and Aga Khan University seen by Health Policy Watch. 

The survey found that Baluchistan, Pakistan’s largest and least populated province of over 12 million people, has the lowest immunization coverage rate for fully immunized children (FIC), at 37.9%. 

Khyber Pakhtunkhwa (KP) province follows with 60.5%, Sindh with 68%, and Punjab, the only province to achieve the national immunization target, with 88.5%. 

Pakistan’s vaccination rate was already one of the lowest in the world before the floods hit, with around 431,000 children not fully vaccinated in 2022, according to the World Health Organization. 

The floods devastated immunization infrastructure across Pakistan and displaced 33 million people, including 16.5 million children, according to UNICEF.

Iftikhar Nizami, a senior advisor at Help Foundation, an NGO working in flood-hit regions, told Health Policy Watch the devastated areas of Baluchistan, Sindh, and Punjab were already poverty-stricken before the floods caused immense damage.

“Health infrastructure was scarce in these areas, and the floods washed away what little there was,” Nizami said. “Even a year later, water is still standing in many areas, and people are displaced. Reaching them to provide basic immunization services is a very difficult task.”

Health ministries at the federal and provincial levels told Health Policy Watch that the floods have made it more difficult for Pakistan to reach the targets set out by its Expanded Program of Immunization (EPI) – Pakistan’s national immunization strategy –  but they are hopeful that they can narrow the gap once health infrastructure is rebuilt. 

“Flood-hit areas face major structural problems, and the residents’ bad days are not over yet,” Nizami said.

Immunization facilities in flood-hit Sindh are still struggling

Health authorities in Sindh, the province hardest hit by the 2022 floods in which 4.4 million acres of agricultural land and 799 lives were lost, are still struggling to cope with the aftermath. 

“Immunization facilities in flood-hit districts are still inundated,” said Dr Muhammad Naeem, Director of Communicable Disease Control at the Health Department of Sinhd. “We are trying to reach out to people with mobile teams.” 

Naeem said there are currently 30,000 children in the province who have not received any vaccines, and that challenges with the availability of vaccinators and their transportation remain in flood-hit districts.

The primary healthcare infrastructure destroyed in the flood is being rehabilitated under a World Bank project, and the province is also working with public-private partners to reach displaced people, Naeem said. 

“If there were no floods in 2022, we would have achieved the target of 80% FIC in the province,” said Naeem.

Pakistan’s immunization indicators fall short of goals

Despite significant efforts by the Pakistani government and its partners, the country’s immunization indicators have yet to reach the expected benchmarks, according to the WHO. The key goals of polio and measles eradication, and measles control, have not been achieved.

A survey conducted by the World Bank and Agha Khan University after the floods found that Baluchistan has the highest rate of zero-dose children at 39%, followed by Khyber Pakhtunkhwa at 10.1%, Sindh at 7%, and Punjab at 0.9%. 

The measles rate per million population in these provinces is 17.72%, 28.22%, 12.71%, and 5.68% respectively.

The Director General (DG) of the Ministry of National Health Services Coordination and Regulations (NHSR&C), Dr Baseer Khan Achakzai, told Health Policy Watch that immunization coverage in the southern parts of Punjab, Sindh, and Baluchistan provinces was already low because of human resource shortages and areas being hard to reach.

“The 2022 floods completely wiped out more than 1,600 static sites used for immunization, which brought coverage down to 64%,” said Achakzai.

Achakzai added that when the homes of millions were flooded, the immunization records of the displaced were often lost. Authorities and international partners spent eight months reaching the scattered population for immunization.

Pakistan’s national strategy aims to achieve universal immunization coverage

Immunizing children with vaccines may avert up to 17% of childhood mortality in Pakistan, according to the WHO. 

Pakistan’s newly drafted National Immunization Policy 2022 of its Expanded Program of Immunization (EPI) envisions “to achieve the universal immunization coverage leaving no one behind to die from a vaccine-preventable disease”. 

The goal of the EPI is to reduce infant, child, and mother mortality and morbidity linked with vaccine-preventable diseases, as per EPI’s schedule, and to limit other infectious diseases (epidemics and pandemics) through emergency vaccination drives. The policy aligns with international commitments and national directions, including SDG 3 and the National Health Vision (2016-2025). 

Dr Mukhtar Ahmed Awan, director of EPI Punjab province, told Health Policy Watch that the immunization coverage in the province’s southern parts had been hit hard by the floods, but that the region has still performed well compared with the rest of the provinces.

“Punjab’s coverage is above 88%, which is the highest, and this is because of multiple interventions adopted by the program to immunize 3.39 million children aged 0 to 23 months annually,” Awan said.

Awan said the provincial program has focused on vaccinating mothers and children in labor rooms of government hospitals, rolling out mass vaccination campaigns, hiring staff for vacant positions, and using technology to get real-time data during immunization.

Awan added that each vaccinator visits each outreach site eight times in 18 months, resulting in the vaccination of approximately 1.8 million children a month.

“We are confident that we can achieve 95% coverage in the next five years,” said Awan.

Rebuilding 1,700 vaccination sites destroyed in floods

The National Immunization Policy 2022 draft envisions achieving more than 90% coverage with the third dose of Pentavalent vaccine among children under 1 year of age at the national level and at least 80% coverage in every district through routine immunization by 2025 and sustaining it.

Achakzai, the Director General of the Ministry of National Health Services Coordination and Regulations (NHSR&C), said the government is working on three strategies to close the immunization gap created by the 2022 floods.

First, the government is rebuilding around 1,700 static vaccination sites that were washed away in the floods with the help of international partners. Second, it is recruiting more than 3,000 vaccinators to bridge the human resource gap. Third, it is installing solar panels in health facilities where electricity provision has been discontinued, as vaccines need to be kept at a certain temperature.

“With these measures, the government is trying to improve the current immunization coverage status by 10 to 15 per cent in the provinces of Baluchistan, Khyber Pakhtunkhwa, and Sindh by February and March next year,” said Achakzai.

Image Credits: UK DFID, OXFAM, UNDP.