Policy note on child immunization in Pakistan: thirty years of progress Pakistan has made impressive progress in immunization coverage in the past 30 years with 117.6% increase in the proportion of children (ages 12 to 23 months) who were fully immunized between 1990 and 2020 (figure 1). Consequently, the incidence of vaccine preventable diseases (VPDs) has reduced. For example, diphtheria by 94% and measles by 88% between 1990 and 2020. Figure 1: Proportion of fully immunized children in Pakistan, 1990 to 2020 76.4% 65.6% 53.8% 47.3% NISP implementation period 35.1% 1990/91 2006/07 2012/13 2017/18 2020 Immunization remains a high priority for the Government of Pakistan and an important part of making progress towards universal health coverage and building resilient health systems. The government initiated the National Immunization Support Project (NISP) in 2016 with financing from partners including the World Bank, the United States Agency for International Development, Gavi the Vaccine Alliance, and the Bill and Melinda Gates Foundation. NISP is a five-year project, scheduled to close in June 2022, which supports and incentivizes the implementation of the government's Expanded Program on Immunization (EPI). NISP has been instrumental in reducing childhood morbidity and mortality from VPDs through strengthening of EPI systems and expanding immunization coverage, particularly between 2018 and 2020. In the 28 years preceding NISP, i.e., between 1990 and 2018, Balochistan increased the proportion of fully immunized children by 62%, Khyber Pakhtukhwa (KP) by 45%, Punjab by 107%, and Sindh by 93%. Whereas during NISP implementation, in only three years between 2017/18 and 2020, Balochistan improved coverage by 31%, KP by 25%, Punjab by 13%, and Sindh by 25%. This points to the tremendous contribution of NISP in improving immunization coverage in Pakistan. Preceding NISP NISP implementation 2 8 Y e a r s 3 Y e a r s 1990 to 2018 2017/18 to 2020 62% Balochistan 31% Khyber 45% Pakhtunkhwa 25% 107% Punjab 13% 93% Sindh 25% Source: TPVICS for 2020 data and PDHS for all other years Despite significant efforts by the government and partners, the immunization coverage is yet to reach the expected benchmarks. The proportion of fully immunized children varied considerably between the provinces, in 2020, from 38% in Balochistan to almost 90% in Punjab (figure 2). Figure 2: Percentage of fully immunized children (aged 12 to 23 months) in Pakistan: 2020 37.6% 61.1% 68.4% 89.9% Balochistan Sindh Khyber Pakhtunkhwa Punjab In comparison to the countries in Eastern and Southern Asia that have similar income levels as Pakistan, immunization coverage is relatively low (figure 3). Figure 3: A comparison of child vaccination status (DTP3) with respect to wealth in Asia: 2019 99 97 98 99 96 99 97 97 99 98 98 99 96 US$ 000 for GDP per capita at PPP 97 98 100 94 93 120.0 90 92 92 90 91 92 89 90 85 102.6 83 79 Immunization gap (%) 78 75 100.0 80 66 68 70 65 80.0 58 60 64.7 50 60.0 45.2 40 35 42.2 40.0 30 29.6 20 18.3 19.2 20.4 12.3 12.312.8 13.614.1 14.3 20.0 8.2 8.4 9.3 10 4.9 5.0 5.3 6.6 6.8 7.0 2.2 2.4 2.8 3.2 3.6 3.7 4.1 4.2 4.5 4.5 4.6 0 Afghanistan Kiribati Solomon Islands Vanuatu Micronesia, Fed. Sts. Timor-Leste Nepal Marshall Islands Tuvalu Papua New Guinea Cambodia Pakistan Bangladesh Myanmar Tonga Somoa India Lao PDR Vietnam Philippines Indonesia Bhutan Mongolia Sri Lanka Nauru Fiji Palau Thailand Maldives Malaysia Japan New Zealand Brunei Darussalam Singapore GDP per capita DTP3 coverage Source: World Bank Databank Notes: 2019 data used for this figure. Per capita values for GDP are expressed in current international dollars converted by purchasing power parity (PPP) conversion factor. DTP3 coverage means three doses of DTP vaccines administered to children aged 12–23 months. Countries included in this figure are drawn from the World Bank's South Asia and East Asia and the Pacific regions. Due to low immunization coverage, incidence of VPDs is also relatively high. Pakistan is one of the two countries in the world, where poliomyelitis is still endemic. In comparison to other countries in South Asia, Pakistan had the second highest incidence of both diphtheria and polio in 2020. With respect to measles, the incidence in Pakistan was the fourth highest (figure 4). Figure 4: Incidence of selected VPDs in South Asia: 2020 27.7 18.9 14.6 13.3 12.4 9.3 4.1 2.6 2.5 1.8 0.1 0.1 0 0 0 0 0 0 0 0 0.4 0 0.1 0 Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka Diphtheria Measles Polio Source: Data from WHO–UNICEF Joint Reporting Note: the figures are expressed as cases per 1 million population. Incidence rate of diphtheria for Afghanistan is for 2019; measles for Afghanistan and Bhutan for 2019. There is a need to continue to strengthen Pakistan's EPI to improve the health of its children. Further enhancing health systems through an expansion of vaccination sites, among others, and prioritizing lagging areas to maximize immunization coverage in underperforming provinces and districts, are two important. In addition, ensuring sustainable financing for EPI, fostering public–private partnership, and exploring innovative approaches for improving vaccine uptake and ensuring readiness of the supply side, can help improve immunization coverage. This is a policy note accompanying the report titled “Immunization for Pakistan's healthy future”, which is available at: www.worldbank.org, with full citations. II