THE name plate on the cemented wall of Al Khidmat Trust, in Meharbadi, a katchi abadi in Islamabad’s F-12 sector, reads ‘Fakhra Sabir’ and also lists her mobile phone number. She is a newly inducted female vaccinator in the health team in the capital.

Inside, in the far corner of a noisy and cramped room, Sabir is busy vaccinating children one after the other as mothers wait patiently with babies in their arms. There is no time to be wasted as there are many youngsters who have to be vaccinated. But Sabir makes sure that she meticulously fills out each child’s vaccination card after inoculating him or her.

The visiting women are clearly at ease. As Sabir vaccinates the children, she talks to each woman, giving her tips about children’s health and hygiene, breastfeeding and even about contraceptives. All the women listen to her intently.

But this is a rare picture as the majority of vaccinators employed by Pakistan’s Expanded Programme on Immunisation (EPI) are male. This makes it difficult for women to open up and freely talk about their health concerns. On their part, male vaccinators neither invite nor encourage conversation. This is just one of the many culture- and gender-related barriers that is likely to have affected the childhood immunisation programme. Other barriers that mothers as the primary caretakers of children encounter in accessing immunisation services include dilapidated or virtually nonexistent transport services, large distances to the health facility where the children are to be vaccinated, inconvenient timings and a long wait at the health centre. Rarely highlighted is the bad service quality, the health provider’s attitude and inferior interpersonal skills. But at least some of these challenges can be overcome if female vaccinators are present at health centres.

Only 3pc of vaccinators in the EPI setup are women.

On average, Pakistan’s routine immunisation coverage stands at 66 per cent, the figure varying from province to province. Punjab takes the lead in coverage at 80pc while Balochistan stands at a dismal 29pc. A comprehensive review conducted by the World Health Organisation in 2010 showed no significant differences in immunisation coverage rates between girls and boys in a global context. However, the review did find that when women are empowered, immunisation coverage increases. In societies, where women are accorded a low status and lack access to immunisation and other health services, both girls and boys are less likely to be immunised.

According to the review, health service providers can improve immunisation coverage by better understanding and addressing the barriers that women face in accessing immunisation and other health services for their children.

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

On paper, the national EPI policy is clearly spelt out with vaccinators responsible for outreach as well as mobile activities; there’s one vaccinator per 10,000 urban and 5,000 rural population. Moreover, the policy recommends two vaccinators per every union council to ensure equitable coverage. But on the ground, things are more complicated as the workforce numbers are deficient by 50pc. And though the EPI policy does not restrict vaccinators to being male, the fact is that out of the 14,000-plus vaccinators, a mere 3pc are women. One reason is mobility constraints, as most male vaccinators can reach remote areas on motorbikes which women cannot. The latter, therefore, are not considered for the post.

But in the age of startups there are examples which can be studied to overcome this barrier. For instance, Careem has hired over 700 women as drivers. Another, more recent example is the Salman Sufi Foundation’s Women on Wheels, an initiative that has trained 5,000 women to ride a motorbike. The current partnership between the two could benefit immunisation services by boosting accessibility for both female vaccinators and women with children.

Other models of accessible, women-friendly transport can be reviewed to help overcome the mobility barrier that is faced by so many. With more female vaccinators inducted into the programme, the other hindrance, ie mothers’ reluctance to interact with male vaccinators, will be overcome automatically. Better conversation and information-sharing with mothers will clear up many myths and misconceptions and help develop trust between government health authorities and the families they serve. Concentrating on this factor alone might prove to be a turning point for reaching those 34pc children who continue to be deprived of immunisation and the ability to fight disease in the country.

The writer is a journalist.

Published in Dawn, March 12th, 2020