Dr. Imran Baloch
The Expanded Programme on Immunization (EPI) is a cornerstone of public health, aiming to protect children from life-threatening vaccine-preventable diseases (VPDs) such as polio, measles, diphtheria, tetanus and hepatitis B. Immunization reduces long-term healthcare costs by preventing outbreaks and lowering disease burdens. In Balochistan, Pakistan’s largest but most underserved province, the EPI faces unique challenges. Despite efforts by the government and international partners, routine immunization coverage remains low, leading to frequent disease outbreaks.
Balochistan lags behind other Pakistani provinces in immunization coverage due to multiple systemic issues. Only 38% of children in Balochistan receive full immunization, compared to the national average of 66% (Pakistan Demographic and Health Survey, 2018). Polio remains endemic in parts of Balochistan due to low vaccination rates. In 2024, out of 74 polio cases 27 cases were from Balochistan, which makes about 36% of total cases of the country. Measles outbreaks are frequent, with over 4,000 cases reported in 2023 alone despite the fact that a significant number of cases are not reported.
The underutilization of fixed EPI sites in Balochistan, highlights several systemic and community-level challenges including geographical barriers, low awareness and misinformation, cultural and social norms like restrictions on women’s mobility prevent mothers from taking children to fixed sites, economic constraints and weak health infrastructure. Underreporting of unvaccinated and Zero Dose children due to weak surveillance of EPI is another issue. While most of the routine immunization coverage coming from outreach sessions, relying on external funding from organizations like UNICEF and WHO for outreach EPI sessions is not sustainable in the long run. Governments should take ownership and ensure consistent funding to maintain uninterrupted immunization services. Regular outreach sessions are critical for reaching remote and underserved populations, reducing vaccine-preventable diseases. Immunization is a lifesaving public good—government ownership and sustainable financing are non-negotiable for protecting every child. Another critical issue is lack of uniformity in outreach EPI sessions across districts, leading to inefficiencies and missed opportunities for maximizing immunization coverage. Key problems due to non-uniform outreach sessions includes inequitable access and weak monitoring. For example, some districts provide more sessions, while others lag, creating coverage disparities. Disorganized schedules make it harder to track performance and address gaps. Just like Polio National Immunization Days (NIDs) and Supplementary Immunization Activities (SIAs), routine EPI outreach sessions should follow a standardized schedule to ensure equity, accountability and better results. There should be a standardized Monthly Schedule (Province-Wide), with fixing the number of outreach days (e.g., 12 or 16 days/month) uniformly across all districts and set fixed start and end dates (e.g., 9th to 20th / 9th to 24th of every month or 3 to 4 fixed days of every week) to synchronize activities. With centralized planning & coordination, provincial EPI cell should issue a fixed calendar (like Polio campaigns) rather than leaving it to districts and ensure all districts follow the same microplan with predefined session sites, dates and targets. There should be a strengthened supervision & accountability in term of real-time monitoring dashboards (like Polio dashboards) to track session completion and coverage, and a Third-party validation (independent monitors) to ensure compliance with the uniform schedule. Just like Polio NIDs/SIAs, uniform EPI outreach will maximize efficiency, equity and impact while standardization ensures no child is left behind due to inconsistent scheduling.
The Expanded Program on Immunization (EPI) in in Balochistan, has faced significant challenges due to politically motivated appointments, mismanagement and lack of technical expertise—especially when the Deputy District Health Officer (DDHO) role, which oversees EPI, is taken as granted and is filled based on political connections rather than merit. Many appointed DDHOs lack public health or technical experience, leading to poor EPI performance and weak monitoring and supervision of vaccination campaigns. These appointees prioritize loyalty over effective service delivery. Weak accountability within the system encourages to corruption and inefficiency in fund utilization. A crucial governance reform needed in Balochistan’s health system for merit-based appointments of DDHOs through a transparent, committee-led process headed by the Director General (DG) Health Services, with members, representative from Secretary Health office, Provincial Coordinator (PC) EPI, Divisional Director of concerned division, District Health Officer (DHO) of concerned district and technical expert from WHO/UNICEF (observer role). Selection criteria should be based on Medical degree (MBBS/BDS) + Public Health/Management degree, with relevant field experience preferred (Already serving as permanent government employee in health department). DDHOs should be appointed for 2-3 years (non-transferable without valid reason) with annual performance reviews like EPI coverage, outreach session quality, district health indicators. While removal should only be for underperformance/misconduct (not political reasons). Currently, political interference and favoritism has weakened EPI performance, outreach sessions and overall healthcare delivery. A transparent, merit-based system for DDHOs appointments will strengthen district health leadership, improve immunization coverage and ensure health equity in Balochistan.
A critical systemic flaw is that, the Quarterly Review Meetings (QRM) of EPI, designed to assess performance and drive improvements, have become ceremonial, low-priority gatherings with no real accountability. Instead of being chaired by the Secretary Health (as intended), they are often downgraded to the Deputy Provincial Coordinator EPI, reducing their authority and impact. Key Issues with current QRMs are lack of high-level participation. Secretary Health & DG Health’s absence signals low priority, reducing district-level seriousness, poor-performing districts face no penalties or corrective actions, fostering complacency. These meetings focus on routine reporting rather than problem-solving & decision-making. Action points from meetings are rarely tracked or implemented. Restructuring EPI QRMs for accountability & impact in Balochistan is the need of hour, with high-level leadership & mandatory participation. These meetings should be chaired by Secretary Health (Non-Transferable Chairmanship) and co-chaired by DG Health Services with required attendees. Weak reviews correlate with stagnant EPI coverage in Balochistan. Instead of passive reporting, there should be structured reviews as per global best practices like Top 3 Best & Worst Performing Districts (with root-cause analysis), Vaccination Coverage Gaps (zero-dose children, dropouts, gender disparities) Outreach Session Challenges (uniformity, missed areas, supply chain issues), Data Quality & Real-Time Monitoring (NEIR & DHIS2 updates, discrepancies), Action Tracker Dashboard (shared with all stakeholders) monitors commitments and Follow-Up Review after 6 weeks to check progress. There should be performance-based accountability measures like publicly rank districts (Green/Yellow/Red zones based on KPIs). Top-performing districts should get additional resources (vehicles, outreach funds), public recognition (certificates, awards from Secretary Health). Underperforming districts must submit corrective plans (with clear timelines). Persistently Poor Performers (PPP) must face consequences with issuance of warning letters to DHOs/DDHOs and replacement of non-performing officers (if no progress in 2 quarters). If EPI performance matters, then high-level quarterly reviews must be non-negotiable—led by the Secretary Health, with real accountability for results.
Balochistan’s EPI program faces deep-rooted challenges, but with targeted interventions, community engagement and stronger health systems, immunization coverage can improve. Polio eradication and measles control are achievable, but only if the government, international partners and local communities work together.
By addressing these gaps, Balochistan can move closer to achieving universal immunization coverage and protecting its children from preventable diseases.
Dr. Imran Baloch is MBBS, MPH.
Email id: [email protected] , [email protected]
