Citizen Trust, Administrative Capacity and Administrative Burden in Pakistan's Immunization Program

"Immunization interactions between parents and frontline bureaucrats are shaped by the former's perceptions of the state and its representatives. Based on public beliefs and past experience, many perceive them to be untrustworthy or unreliable..."

Pakistan is one of two countries where wild polio is still endemic and is ranked third for un- or under-immunised children. Why is this the case, when considerable donor and government funds have been spent on Pakistan's Expanded Program for Immunization (EPI)? One factor is that, unlike antibiotics or other medication, vaccines are administered when a child is not presenting with any symptoms. Therefore, significant learning, compliance, and psychological costs are imposed as parents try to gather information and cultivate trust in governmental (EPI) provision of vaccines. The consequence can be vaccine hesitancy: suspicion or even outright fear of vaccination. Based on a year of mixed-methods research in district Kasur in Punjab, Pakistan, this article examines vaccination as a site of interaction between citizens and the state and applies the concept of administrative burden to explain vaccine hesitancy in Pakistan.

The research involved an exploratory survey of 179 households and qualitative fieldwork (semi-participant observations and interviews of 20 provincial and district health bureaucrats) designed to understand issues in the supply and demand of immunisation services.

As the fieldwork and literature review revealed, bureaucrats often control what information or assistance they offer to citizens, and they can and do make judgements about parents' priorities and care for their child. Furthermore, the perceived imposition of vaccines is in stark contrast to the state's usual absence or unsatisfactory performance in low- and middle-income countries (LMICs) like Pakistan, which can cause resentment and fear of vaccines as a possible means for the government to control the population. For instance, in some communities, vaccines are considered a conspiracy to render the population of Muslim nations sterile. In the former Federally Administered Tribal Areas (FATA) in the northwest of Pakistan, some people perceive the government as caring only about polio and none of their other needs. As in other countries (e.g., Nigeria and India), citizens in Pakistan have used polio vaccination as a bargaining chip with the state, refusing to vaccinate their children until their specific demands are met.

"Citizens' experiences of discrimination and injustice at the hands of the state stigmatize any further dealings with that state and its representatives (Independent Monitoring Board of the Global Polio Eradication Initiative 2019, p.14), raising psychological costs for citizens in engaging with vaccination programs. Furthermore, since the state is seen as untrustworthy and unapproachable, the most readily available avenue for information on vaccinations in an underserved region becomes inaccessible, increasing both learning and compliance costs for citizens."

Furthermore: "Even where the state is present - in the political heartland of Punjab, where Kasur is located - it can be difficult to get citizens to trust state services, even when provided free of charge and at their doorstep. Citizens often have valid concerns regarding the uncertainty and safety of state service provision, emerging, for example, from media reports of fake medications causing the death of patients in government hospitals (WHO [World Health Organization] 2013; Interviews 7 and 10). Such concerns drive up learning costs as citizens must be more diligent and seek alternative sources of information, and psychological costs as citizens experience the stress of ensuring the health and safety of their children in their interactions with the state."

As the interviewees revealed, the context in which parents interact with frontline bureaucrats - e.g., vaccinators - can be stressful and can even reinforce inequalities: Previous research has found that wealthier parents are more likely to be treated with respect by health service providers. Most survey respondents claimed that the vaccinator did not explain the need for the vaccine being administered to a child and complained that vaccinators did not explain how vaccines would help or how they work. "Learning and psychological costs become even more problematic when parents are unaware of the side effects of vaccines. Fear for their children's wellbeing - in part the consequence of high learning costs and the absence of information - discourages parents from vaccinating their children....These costs also make parents more fearful and susceptible to misinformation that frontline health workers are ill-equipped to counter..., further impacting trust in the state. Fear closely shadows immunization campaigns in Pakistan."

Distrust is exacerbated by policies such as the Pakistani state's response to polio vaccine refusals, which was, until recently, to arrest the parents. "Such policies are perceived by parents as a loss of personal autonomy and the imposition of the state's might on matters related to the health and wellbeing of their children....[S]trong-arm tactics fail to get a sustainable commitment to vaccination from the parent, who begins to associate immunization with the use of force by the state (Interview 1)."

As argued here, low administrative capacity (overburdened staff, inadequate facilities, and rushed digitisation) has a multiplier effect on administrative burdens imposed on parents in accessing immunisation programmes. For example, digital dashboards have added to the vaccinator's work, meaning longer waiting times and thus higher psychological costs for citizens. In 2012, the Punjab government introduced an attendance monitoring system for vaccinators' attendance and digital entry of the details of each child immunised. Already overburdened vaccinators feel additional pressure to ensure they meet set targets for children immunised, which incentivises false entries (Interview 4 and 5) and provides little motivation/time to educate parents or alleviate their fears.

Thus, especially in interactions initiated by the state itself with the expectation of full compliance (as in the case of vaccination), context, prior experience, and citizen trust are crucial factors that determine engagement and uptake. Furthermore, the state's administrative capacity - or lack thereof - can contribute a multiplier effect on learning, psychological, and compliance costs experienced by citizens. In LMICs in particular, therefore, the state is advised to: recognise the imposition of burdens, understand their effects, particularly on the vulnerable and marginalised, and develop a contextualised policy response to equip the state to take on these burdens.

The researchers hope this citizen-centric, contextualised approach to assessing the impact of state capacity and trust on the challenges faced in accessing public services could inform the work of other scholars studying the particularities of citizen-state encounters in LMICs.