The Synergy between Expanded Program on Immunization and Polio Eradication Initiative in Pakistan: A Policy and Program Exploration

"The Government advised synergy between EPI and PEI to ensure the legacy of polio and ultimately the sustainability of the polio-free status of the country..."

Pakistan, a polio-endemic country, has attempted to combat the disease through an Expanded Program on Immunization (EPI) since 1978 and a Polio Eradication Initiative (PEI) since 1994. This study explores the EPI-PEI synergy and its operationalisation, especially for the zero-dose children at various levels, as well as the synergy-related enablers and barriers. It offers suggestions to enhance synergy in the future.

The researchers carried out a national-level exploration comprised of 30 individual interviews and 8 focus groups. The 120 participants included government officials and representatives from civil society and partner organisations working for immunisation, along with EPI vaccinators and community-based vaccination (CBV) workers of PEI in two provinces, i.e., Punjab and Khyber Pakhtunkhwa (KP).

Four themes emerged:

1. "Synergy" has different meanings for different stakeholders. The National Emergency Action Plan (NEAP) specifies that the objective of EPI-PEI synergy is to make optimal use of polio resources and to improve routine immunisation (RI) in the country. While identifying NEAP as the key policy document, the participants from the provincial- and district levels noted that the district and below levels do not get a chance to provide input. Moreover, the operational guidelines agreed by all parties are not available, leading to confusion. "While they highlighted issues like zero-dose and birth-dose, which are the fundamental problems underlying a lack of synergy, it appeared that they had not been consulted during the formulation of this vital pillar of immunization programming in Pakistan. Past studies...on policymaking mention the problems of top-down, ad-hoc policies developed without any need-assessment or trickle-up of the input, which is visible in the case of PEI-EPI synergy as well."
2. Some synergies (e.g., sharing of surveillance data by PEI) are in place, while additional (e.g., transferring human resources and enhancing community engagement) can be created. "None of the discussants brought up the issue of building upon the knowledge that PEI has gathered over decades, in terms of surveillance in difficult-to-reach areas, reaching the last child to provide OPV, understanding, and addressing people's perceptions about the vaccine, including its acceptance and hesitancy."
3. The EPI and the PEI have become two unequal programmes whose district- and community-level staff do not have confidence and mutual trust because of political factors, visibility, and funding. "The feeling that PEI enjoys a higher level of ownership from the national Government and international donors, and better access to the highest level of governance in the country, impedes the input from EPI and needs attention." High-level commitment from the Ministry and the leadership of both PEI and EPI programmes was perceived as an enabler.
4. Synergy can be fostered through clear policy and operational guidelines, including roles and responsibilities. Furthermore, the leadership needs to ensure that actionable information on zero-dose children reaches the field force, whether EPI or PEI. When polio workers collect data from the family is the best opportunity to assist the EPI in demand-generation activities. Polio teams can achieve this if they inform the family about the immunisation needs of their child, the place where the child can get the vaccine, and the time when it is the easiest for the family.

In conclusion: "The immunization stakeholders in Pakistan understand the importance of synergy between PEI and EPI, and there is a willingness on both sides to support each other. Both programs have demonstrated their strengths and contributed through their respective role to Pakistan's response to COVID-19. The same level of coordinated response can be made possible for polio eradication, provided the concept and implementation of synergy between the two are clarified, and a future course of action is defined for both the programs."