“Keep this immunisation card safe and remember to take it to the health facility on your next visit. In all you will have to make six visits to the health facility and your child will be protected from the nine vaccine-preventable diseases,” says Rizwana Yasmeen as she explains the schedule to a young mother at the Basic Health Unit (BHU) in Mirpurkhas, some 250km from Karachi.

“Remember it’s free. You don’t have to pay anything,” she adds when the mother and the baby are about to leave.

Full of energy and vitality, Yasmeen, 24, is among a brigade of almost 100,000 Lady Health Workers (LHWs), in Pakistan, trained under the government’s National Programme for Family Planning and Primary Health Care. Yasmeen makes sure that she uses all her powers and time to ensure that the mother returns to the centre to complete her child’s immunisation.

Explaining the importance of vaccination to parents, especially mothers is vital for the success of Pakistan’s immunisation programme; for this health workers need to be trained in communication skills

“The district’s [immunisation] coverage would increase manifold if every health worker were equipped with the same convincing skills as Yasmeen,” says Dr Khalid, medical officer at the BHU, observing the scene. He did not quite expect the talk between the two women to generate such an interest on the mother’s part to ensure that her child is fully vaccinated.

“There is no one else to give her that information. I am her only source. So I have to make sure she has absorbed everything I said. They look upon me with great respect,” points out Yasmeen.

Whether being a woman gives Yasmeen an edge to relate with mothers, or whether it has something to do with her skills, is hard to tell. One thing is for sure, the mother who just walked out of the health facility will not miss her child’s next due date for vaccination.

Launched in the 70s, the Expanded Programme on Immunisation (EPI) aims to protect children by immunising them and reducing mortality rate caused by vaccine-preventable diseases. It includes free-of-cost vaccination of all children between zero to 15 months against nine vaccine-preventable diseases (childhood tuberculosis, poliomyelitis, hepatitis B, diphtheria, pertussis, neonatal tetanus, haemophilis influenza B., measles and pneumonia), and pregnant women against tetanus.

In spite of all these steps taken to improve health indicators throughout the country, the mortality rate from vaccine-preventable diseases is still quite high.

One of the reasons quoted by caregivers for not completing the vaccination regimen is poor treatment, or experience with health workers at the health facility. Communication experts believe that by building the capacity of health workers, the government can improve caregivers’ experience at the health facility and ensure reduced dropouts.

While visiting a hospital in Karachi last month, Anuradha Gupta, deputy CEO of Gavi, an organisation that works on bringing together the private and public sector to improve access to vaccinations in developing countries, expressed surprise when she came to know that the vaccinators administering routine vaccination were predominantly men.

Gavi has been supporting Pakistan’s National Immunisation Programme since 2001 through different windows of support, with $935 million total committed funds as of January 2016.

Does the fact that Pakistan only has male vaccinators inhibit coverage? Do some women find approaching a male vaccinator a barrier? And decide not to take their children to be vaccinated? These were some of the questions that came to her mind.

Prior to joining Gavi, Gupta served as additional secretary at India’s ministry of health and family welfare, and played a leading role in the country’s efforts to eradicate polio transmission. Speaking from her experience in the subcontinental context, she feels it is easier for women to have a conversation with a female health worker.

In a cultural setting like Pakistan in particular, where women may be diffident and constrained in their communication with unfamiliar men, not having female vaccinators could be a serious missed opportunity for delivering immunisation, together with other reproductive, maternal and child health services.

Pakistan is a large country with high child mortality and low immunisation coverage rates. Every year more than one million Pakistani children miss out on a full course of the most basic vaccines. Poor coverage rates put children at risk of dying from vaccine-preventable diseases, and is one of the key reasons why Pakistan did not achieve the United Nation’s Fourth Millennium Development Goal (MDG 4) — reducing child mortality by two-thirds from a 1990 baseline.

One of the reasons quoted by caregivers for not completing the vaccination regimen is poor treatment or experience with health workers at the health facility. Communication experts believe that by building the capacity of health workers, the government can improve caregivers’ experience at the health facility and ensure reduced dropouts.

“As more and more LHWs are being trained to provide vaccinations, we expect to increase coverage rates throughout the province,” says a confident Dr Agha Ashfaq, programme manager Sindh EPI.

Better coverage rates do not just translate into improved quality of life but could also be better in monetary terms. To quantify the economic benefits of immunisation, a new study, conducted by Johns Hopkins University earlier this year, provides the most comprehensive evidence to date to support this claim.

Assessing the return on investment, the study, covering 94 low and middle-income countries, shows that for every dollar invested in childhood immunisation, one can expect to save $16 in healthcare costs, lost wages and less of productivity due to illness and death.

If we take into account the full value of people living longer, healthier lives, the return on investment rises to $44. In total, immunisation will yield more than $586 billion in economic benefits in the period 2011-2020.

These numbers provide compelling evidence that can help make the case for increasing domestic investments in immunisation. Research has shown the effectiveness of health workers — vaccinators, LHWs and community health volunteers — as frontline communicators and behaviour change agents on health issues in the community. Thus the role of interpersonal communication is of utmost important for the success of the EPI, if we are to save our children from dying.

As along with the rest of the world, Pakistan marks the beginning of World Immunisation Week (24-30 April), this is a good time to debate these issues. The theme for this year is ‘Close the Immunisation Gap’, which seeks to draw attention to the critical importance of reaching the unreached, stressing the challenges we face.

Celebrated throughout the world, the week aims to raise public awareness about how immunisation saves lives, encouraging people everywhere to get themselves and their children vaccinated against deadly diseases. Here’s hoping Pakistanis also hear the message and follow up on it.

Published in Dawn, Sunday Magazine, April 24th, 2016