Khadija at 18 months collects all her strength to walk up to her mother standing just a few feet away. Rida, six, stands quietly on the side, while their three-and-a-half-month-old brother, Allahdad, takes refuge in their mother Zainab’s arms. Both the older children suffer from complications that arose from them catching measles.

The most tragic part for health experts, however, is that Zainab’s children’s illnesses could have been avoided. Measles, they point out, is among many diseases that can — and should be — vaccinated against at an early age. And if it weren’t for Zainab’s neighbour who informed her about childhood vaccination programmes at the Rural Health Centre in Tarlai (20 km from Islamabad), her youngest son could soon have been sharing the fate of his siblings.

Health experts, policymakers and doctors emphasise that a course of vaccines given in the first 15 months of a new-born’s life can protect her or him from 10 different life-threatening diseases. These vaccines are available at every basic health unit and various centres of the Expanded Programmes on Immunisation across the country.

A focus on polio eradication may have adversely affected routine immunisation against other childhood diseases. Now the KP government and Islamabad are making it mandatory

Globally, countries are fighting against eradication of these diseases and have decreased the number of deaths attributed to these 10 vaccine-preventable diseases. But Pakistan is still struggling.

Considering this, Senator Ayesha Raza Farooq tabled the Islamabad Mandatory Vaccination and Protection of Health Workers Act, 2015. The bill, however, is confined only to the Islamabad Capital Territory (the cities of Islamabad and Rawalpindi). On May 18 , 2017, this bill was moved in the lower house by National Assembly member Zahra Wadood Fatemi.

Similarly an amendment was passed by the Khyber Pakhtunkhwa Provincial Assembly on May 12, 2017 to make vaccination against all preventable diseases compulsory and establish a mechanism to persuade parents for the immunisation of their children.

“The Bill will pressurise parents to get their children immunised. Once it becomes a legal document, people will be bound to complete the vaccination regimen of their children,” Fatemi told Dawn.

However, she added, at present the bill’s application is limited to the ICT unless Article 144 of the Constitution is used. It is because after the passage of the 18th Constitutional Amendment and the resulting devolution of powers in 2010, provinces have taken charge of their health plans. But the same bill can be introduced by any provincial assembly.

If Article 144 is used and a resolution is passed by two provincial legislatures then the bill can be legislated by the federal government, and the bill shall be implemented nationwide, says Fatemi, commenting on the need for a uniform law across the country.

Commending the initiative as an important step on behalf of the government, Dr Zulfiqar Bhutta, founding director of the Centre of Excellence in Women and Child Health at the Aga Khan University, Karachi, says: “The idea is not to penalise the parents or deprive them of any basic right.”

At the same time the Bill is binding on the government to “establish, maintain or declare health facilities adequately equipped to maintain vaccine preservation (cold chain) and to administer vaccination to all children of prescribed age group and to form outreach teams for administering vaccination to all children of prescribed age group so identified by the local area administration.”

Unfortunately, over the last two decades, ever since we have disregarded routine immunisation and diverted all resources to polio eradication, our coverage has worsened leaving a huge cohort of unimmunised children.

And yet passage of these laws is not enough. “For vaccines to prove effective, it is extremely important that they are provided to as many children as possible. Even if one child remains unvaccinated, he or she is vulnerable to risk,” says Bhutta.

For that to happen, said Farooq, there has to be “strengthening of the synergy between the Polio Eradication Initiative (PEI) and Expanded Programme on Immunisation (EPI).” Once polio is contained, Pakistan cannot sustain its gains if routine coverage is low,” she added. “Evidence has shown a strong correlation between polio cases and low routine immunisation. More than 80 per cent of polio cases have been found in areas where routine immunisation is low,” said Senator Farooq, who is also the prime minister’s focal person on polio.

“No doubt eradication of polio is important; but so is the eradication of other childhood diseases,” says Dr Meher Taj Roghani, deputy speaker of the Khyber Pakhtunkhwa assembly, who is a paediatrician by qualification. “Unfortunately, over the last two decades, ever since we have disregarded routine immunisation and diverted all resources to polio eradication, our coverage has worsened leaving a huge cohort of unimmunised children,” she says while talking to Dawn over phone from Peshawar.

But even before the bill is enforced, there is a window of opportunity to create awareness about the immunisation regimen and how to protect infants from these childhood diseases and where to go, says Dr Roghani. She points out that even today, many mothers erroneously believe that polio drops administered to their kids during door-to-door campaign means the infant has been immunised against all diseases. She says parents must know about the nearest health facility from where they can get their child immunised.

The Bill will pressurise parents to get their children immunised. Once it becomes a legal document, people will be bound to complete the vaccination regimen of their children. Fatemi, told Dawn. However, she added, at present the bill’s application is limited to the ICT unless Article 144 of the Constitution is used.

“Vaccination or health certificates are systems that open doors of opportunities for children.” However, Bhutta feels, it is necessary to facilitate the under-privileged in the process at the implementation stage of the legislation. “If people go to facilities to get their children vaccinated, and there is no vaccine or vaccinator at the facility, it just leads to inequity and injustice. So supply side must also be handled simultaneously.”

However, all is not bleak. The last Pakistan Demographic and Health Survey (PDHS) 2012-13 shows that the proportion of immunised children in Pakistan has increased from 35pc in 1990-91 to 54pc in 2012. But look at the numbers closely and you will find variations in immunisation coverage in provinces and districts, and by gender.

It is true that the last PDHS 2012/2013 showed an overall 54 percent national immunisation coverage, but a lot has changed in the past two years, explains Dr Saqlain Ahmed Gilani, National Programme Manager, Expanded Programme on Immunisation.

He reiterates that according to a Pakistan Social and Living Standards survey 2014-2015 overall routine immunisation coverage has improved. Moreover, Federal EPI is shortly going to hold a countrywide survey on coverage of routine immunisation to get a more accurate picture.

“It is not that all is hopeless; there are success stories, and there is a lot to smile about. At the same time, there is much that needs to be done and there are gaps that need to be filled,” says Dr Gilani.

Published in Dawn, EOS, June 11th, 2017