Polio Eradication and Health Systems in Karachi: Vaccine Refusals in Context

"Community and health worker engagement will be key to polio eradication in Karachi, Pakistan."

Drawing on research conducted in early 2012, this study focuses on factors affecting parental acceptance of oral polio vaccine (OPV), and health worker motivation to deliver it, in SITE Town, an area of the mega-city of Karachi, Sindh province, Pakistan that in recent years has harboured wild poliovirus (WPV). In conducting participant observation, interviews, and a document review, the researchers' aim was not to evaluate the effectiveness of the polio programme but, rather, to qualitatively describe some challenges workers faced and explore why some parents refused polio vaccine. In short, in SITE, vaccine acceptance and worker motivation were shaped by the discrepancy in funding and attention for polio eradication campaigns as compared with routine services. Hence, the researchers propose short-term improvements to routine immunisation (RI) and sanitation in key polio-endemic areas, coupled with a long-term focus on sustainable improvements to RI and broader health services.

As they explain, SITE's diverse population includes large numbers of internally displaced persons (IDPs), most of whom are ethnic Pashtuns from the Federally Administered Tribal Areas (FATAs) and Khyber-Pakhtunkhwa (KP) in Northwestern Pakistan. They are disproportionately affected by polio and are more likely than other populations to refuse the polio vaccine. Working in SITE Town's health system involves challenges such as a security issues, severe shortage of staff (especially in union councils (UCs) with many IDPs), medication stockouts, and low levels of national funding (and wages) combined with weak accountability at the provincial level. In Karachi, only around 40% of children were fully immunised with the third dose of the diptheria-tetanus-pertussis vaccine (DTP3) in the Pakistan Social and Living Standards Measurement (PSLM) survey (2010). The Global Polio Eradication Initiative (GPEI) delivers OPV in resource-intensive door-to-door campaigns; in SITE Town, there were 8–12 in 2010. The discrepancy between polio and other services was particularly acute in UC 9. Because that area had recently seen two polio cases, they had 12 door-to-door campaigns in the year of this research. Thus, the area respondents said had the poorest RI in SITE Town also had the most intense campaign schedule. "Especially given the low pay, relentless pressure to achieve results in campaign after campaign wore on workers."

The researchers explain that understanding the reasons for refusals is important not only because they directly reduce vaccination coverage, but also because refusals have a negative effect on polio workers' motivation. Among IDPs in particular, parental vaccine refusals stemmed from a distrust of government and international actors that provided few services but administered polio vaccine door-to-door every month. Refusals were clustered in areas with poor RI and poor sanitation. In the context of IDPs' understandable distrust of the health system, rumours were common, particularly that the vaccine caused infertility and was "American". One respondent noted, "We have people here who have political affiliations and they do not want their information to be leaked out....There is a law and order problem and they think that we are police informers." One lady health worker (LHW) said that "dealing with refusals - because it is often very difficult to convince people to take the vaccine" was her most time-consuming activity during campaigns. Furthermore, interacting with refusal parents can be frightening, as in the case of a male health worker who was hit in the face by an angry father.

In a context where children receive few or no other health services, the researchers argue that "pushing harder to get parents to accept polio vaccine is unlikely to change their minds; rather, increased pressure focused on this one issue may well lead to increased resistance." Noting this, in 2012, high-level staff said the polio programme was increasing attention to RI. In 2016, these plans are in motion. Various initiatives aim to broaden the services provided with polio vaccine. A Pashtun-specific communications strategy has been developed. Worker training has been enhanced, and efforts are being made to get polio workers paid on time. Thanks to such developments, a UNICEF study showed an 80% reduction in refusals in endemic high-risk areas nationwide as of 2014.

However, in 2015, SITE Town, and particularly UC 9, remained underserved by the government health system. There was still no government health facility in UC 9 and no government doctor in all of SITE Town that spoke Pashto. Although many people in SITE Town want to provide better services in high-risk areas, the researchers say there are real barriers to achieving this. The issues involved are complex and political. In the longer term, the GPEI's legacy process aims to provide support to broader health services. "[I]n the short term, higher quality RI and health services may be critical for the narrow and immediate goal of eradicating polio." Specifically, the researchers focus on 3 areas where targeted interventions could pay dividends for polio eradication: (i) water, sanitation, and hygiene (WASH) - e.g., education about the use of water treatment systems could be integrated with polio messaging; (ii) LHW services - e.g., polio campaign trainings could be an opportunity to learn about area-specific shortages and follow through with essential supplies; and (iii) RI - e.g., international and national pressure and funding for infrastructure and staff for RI in high-risk areas such as UC 9.

"The strategies we propose here would supplement, not replace, efforts to build broad-based health systems. Sustainable RI provision and constructing water and sanitation infrastructure are complex, long-term projects."

Editor's note: This paper has been published as part of a United States Agency for International Development (USAID)-funded initiative to increase the number of peer-reviewed papers on routine and polio communication and to ensure that academics from a range of countries, including those facing the greatest polio and routine immunisation challenges, are supported in getting their research peer reviewed, published, and widely disseminated through The CI and the new journal Global Health Communication.