Pakistan: Publications on Immunisation Decisions

Most of the funding available for immunisation programmes worldwide is going into the development of new vaccines. But new vaccines are unlikely to reach households that are not being covered by existing vaccination services. Getting more children vaccinated is not just a matter of supply but also of demand — a demand that is determined by decisions made at the household level where families with very limited resources weigh the costs and benefits of childhood vaccination in the midst of very limited opportunities and many necessities.

From 2004 to 2007 CIET conducted a randomised cluster controlled trial to test a low cost community-based approach to extending the coverage of childhood vaccination in the Lasbela district of Pakistan. The trial focused on increasing demand for vaccination by helping communities reflect on their own cost-benefit criteria for getting their children immunised.

Results of this trial are reported in five separate articles of a special supplement to the October 2009 issue of BMC International Health and Human Rights.

One article reports on a systematic review of available literature estimating the impact of demand-side interventions on uptake of routine childhood vaccination. The authors found that the cost-effectiveness of demand-side interventions has not been adequately assessed, but, judging from limited data, some may prove to be very cost-effective.

Another describes a “balance sheet” that summarized published evidence on benefits and possible adverse effects of measles vaccination and may be useful as a communication tool when applied to up-to-date local evidence.

A third article examined local determinants of measles vaccination in four separate districts of Pakistan and found that good local information about vaccination rates and associated variables is important to allow effective and equitable planning of services.

A fourth analysed knowledge, attitudes and discussion around vaccination uptake in Lasbela district and found that stagnating rates of vaccination coverage were closely related to increasing inequities among families in that district.

The central article of the series describes the intervention itself, which consisted of three structured discussions held separately with male and female groups in each of 18 intervention clusters. One discussion shared findings about vaccine uptake from the baseline study; a second focused on the costs and benefits of childhood vaccination and a third dealt with local action plans. This intervention doubled the odds of measles vaccination in the intervention communities and trebled the odds in favour of full DPT vaccination. This relatively low-cost “knowledge translation” intervention significantly increased vaccine uptake without relying on improved services, in a poor district with limited access to services. This could have wide relevance to efforts at increasing vaccination coverage in developing countries.

This work was supported with funds from Canada’s International Development Research Centre.

See the Pakistan project pages for more information on the Lasbela experience.