THAT Pakistani parents mark their children’s fingers because they do not want them to be vaccinated is correct. That this outright refusal and other forms of vaccine hesitancy is the cause of poor vaccination rates is incorrect. It is a symptom of the larger and critical underlying problem, one that that Bill Gates calls “sub-optimal management and increased community resistance to vaccination”.

The question is why are parents hesitant or why do they refuse a lifesaving service for their children, one that comes to their doorstep? Because they are suspicious of the system which they feel is not aligned with the best interests of their child.

What makes them think so?

To explore possible answers to this question, funded by the Shahid Hussain Foundation, the Lums faculty has completed a research study in a low-income district, Kasur. The results provide a range of reasons on the demand side and the supply side of vaccine delivery, for vaccine refusal and hesitancy. The study also reveals what “sub-optimal management” looks like and how it can be fixed.

On the demand side, there is parental ignorance and distrust of the health delivery system, and on the supply side there is a stunted and inappropriate programme design that is managed in an inconsistent and sub-optimal fashion.

Parents are suspicious of a system which they feel is not aligned with the best interests of their child.

Parents understand that children can be visited by disease, and need medical treatment to rid them of it. While familiar with the treatment, parents are ignorant of disease prevention, so it does not make sense to them to give medicine (vaccine) to healthy children. They are not aware of the side effects of vaccines — rash, fever, pain at the injection site, lethargy, loss of appetite, occasional diarrhoea, which they attribute to vaccines. Some parents attribute malformation in children to vaccines.

Parents are suspicious of the way the health system operates to deliver vaccines. When they take the child to a health centre for a health problem, even when their child suffers side effects from the vaccine, the system is unresponsive. The local health centre is closed or there is no doctor or no medicine. The resulting suspicion of the same system that yesterday came to their home to give them medicine (vaccine) especially polio drops is understandable.

People’s health-seeking behaviour is crucial to their propensity to accept vaccines. This behaviour is based on knowledge and credibility in guidance of wise elders, who pass on traditional knowledge and who are believed more than the representatives of an unresponsive system.

While the vaccines are pushed on children, parental concerns remain unanswered. Why would I give medicine to my healthy child? Why do you give so many vaccinations together? What if the vaccine gave the disease to my child? My child was premature/of low birth weight — given that he was so small, wouldn’t the vaccines be dangerous for him? Why immunise him against diseases that we don’t see in our community? Since these questions are not answered satisfactorily, parents think there has to be some other reason for this very aggressive dispensation of medicine (vaccine).

Parents want to retain ownership of their children’s well-being. If they feel judged we lose them. “When someone can actually answer my questions, and not just bully and shame me, then I’ll consider it,” said one mother of three children less than five years of age. Weight loss and addiction psychologists have learnt that direct health advice never works. To change health-seeking behaviour you need to work with people’s anxieties and respect their opinions.

On the supply side there are the usual problems of poor infrastructure — the absence of routine vaccination service, lack of effective monitoring of supplies, inadequate supervision of vaccinators, chronic staff absenteeism and difficulties in maintaining the cold chain due to electricity failure that leads to new problems. For example, vaccines stored in freezers in Basic Health Units or Rural Health Centres are placed in ice buckets during frequent power breakdowns. Maybe the cold chain is maintained, but this action adds another problem: the water unglues the labels from the vials. Parents can see this and are rightly suspicious of potential harm.

Vaccinators are not part of the health system and are hired for vaccination drives; inadequately trained with little supervisory support, they have many problems in the field. For instance, they claim they are not paid on time. Or they are expected to pay for their transport. Mid-level managers cannot solve problems in the field, since they do not have the required authority.

The confusion is compounded because the EPI and polio eradication, as vertical programmes are directly under federal authority. Programme activities are decided in advance, donors provide the earmarked unchangeable funding, specific to a particular activity. Even though not directly responsible for the programme, district and provincial administration are expected to ensure results.

The prime minister has said that the “government will take 100 per cent ownership of the programme, from disease control to eradication, and 100pc accountability would be assured across the board”. Hopefully, his team will take this seriously and take into account the information from the field in the ‘various initiatives’ taken for ‘perception management’, and in their in plans to deal with ‘anti-vaccine propaganda’. Large objectives are fine, the devil is really in the detail.

We need to understand that if we do not push through to eradicate polio, there is a danger that polio can re-emerge in the world — as measles did recently in US. To successfully eradicate polio and other communicable diseases, the authorities need to rework the programme’s design and field activities in light of real-life constraints on the demand and supply side. Detailed and specific education programmes about disease prevention and vaccination schedules focused on parents, to be delivered consistently by trained and credible staff, should be the first component of this reworking.

The writer, a public health specialist, is a research fellow at Lums. She is the author of So Much Aid; So Little Development. Stories from Pakistan.

Published in Dawn, August 25th, 2019