Pakistan faces problems in the vaccine delivery services in terms of low enrolment rates and loss to follow-up in immunization programs, data collection, management and paper-based registries of vaccines administered. The amalgamation of these problems hampers the overarching aim of improving immunization outcomes in Pakistan.
Zindagi Mehfooz (Safe Life): Program Components
Immunization coverage, follow-up and timeliness are few indicators that help gauge the effectiveness of service delivery of vaccines. Interactive Research and Development’s (IRD) Zindagi Mehfooz (Safe Life) is an initiative that aims to employ innovative techniques to refine the immunization program in Pakistan and move towards an integrated platform to improve maternal and newborn child healthcare in Pakistan.
Zindagi Mehfooz employs a phone-based electronic registry system to collect data on vaccines administered, and maintain an online database for tracking immunization schedules. The program also employs Radio Frequency Identification (RFID) tags with Unique IDs for individuals on Expanded Program on Immunization (EPI) immunization cards to track the record of immunizations. RFID tags are linked to lottery prizes to incentivize parents to enroll their children in the program and complete the immunization schedule correctly. The lottery prizes are used as conditional cash transfer to change parents’ behaviors towards immunization. This initiative also sends out text messages to the parents to remind them to adhere to follow-up dates and timely schedule completion.
Engaging the Government
Engaging with the public sector is essential to tackle the far-reaching problems of child mortality that stem from poor immunization outcomes. Zindagi Mehfooz is implemented in public and private EPI centers to ensure diffusion of this innovative health solution. This program incentivizes government-employed vaccinators to use a phone-based registry instead of paper. This practice reduces the chances of fraud and improves data collection and management of the administered vaccines. Furthermore, mobile phone technology facilitates cashless transfers. Electronic vaccines registries ensure that government captures all relevant data pertaining to vaccines delivery. Consequently, comprehensive database can assist the decision makers to design and implement effective policies to improve immunization outcomes. Although this program has potential to make the vaccine delivery services in Pakistan more effective, more effort is required to advocate its effectiveness to policy makers at provincial and national level.
For this program to be adopted and scaled-up in Pakistan, a proactive evidence-based approach is essential to engage the government to replicate this program with required modifications in different areas. With this approach in mind, the program managers hypothesized that Zindagi Mehfooz would result in improved timeliness, follow-up and coverage of vaccinations in the target population. To substantiate the efficacy of mHealth supported immunization services, program managers Dr. Asad Zaidi, Dr. Subhash Chandir, and Dr. Vijay Kumar led the impact evaluation of Zindagi Mehfooz Program.
The hypotheses of Zindagi Mehfooz included whether the intervention improved immunization follow-up, coverage (enrollment/take-up rate) and adherence to the vaccination schedule or timeliness. The impact of intervention on incidence of preventable diseases, covered by routine immunization, is also under evaluation.
The sample size of the study was 325-350 each in the treatment/intervention group (Two EPI centers at Korangi, Karachi) and the control group (Two EPI centers at Landhi, Karachi). The experimental design is randomized evaluation. The study targets those who come in for the first vaccination, called Bacillus Calmette-Guerin (BCG), in the EPI schedule. The intervention group population was subjected to interventions of interactive reminders and conditional-cash transfers. The control group population did not receive to the aforementioned interventions. In both the control and intervention groups, the relevant EPI vaccines were administered.
Indicators measured by the impact evaluation include socio-economic indicators, maternal indicators and antenatal history, which will help determine the timeliness of follow-up and completion of the immunization. The evaluation study will help in determining if there is a positive causal effect of the CCTs and SMS reminders on the aforementioned outcomes. Moving forward, a pragmatic randomized control trial would help in contextualizing the program’s efficacy across varying settings.
Although Zindagi Mehfooz is a promising innovation, a comprehensive impact evaluation is needed to substantiate the implementation of relevant policies. Moreover, evidence-based evaluations are need to discover a causal link between conditional cash transfers and interactive reminders and their impact on improving immunization outcomes in terms of enrolment, follow-up and timeliness. The results will be crucial for government adoption and replication of this initiative at provincial and national levels.
Zindagi Mehfooz can be used for capacity building of Government of Pakistan’s EPI program and employ public-private mix to improve immunization outcomes in terms of increase in immunization completion and better timeliness outcomes. An in-depth evaluation can make the case for policy makers and government to advocate for increased budgetary allocations for immunization-related programs. The findings from this impact evaluation can be used to support calls for an integrated platform of maternal and newborn child healthcare with harmonized efforts to improve child and maternal mortality rates.
Components of behavioral economics and mHealth technology can be incorporated by various health programs to improve health outcomes. With efforts in behavioral change by incentivizing patients and vaccinators with conditional cash transfers, Zindagi Mehfooz has the potential to positively transform the vaccine delivery system in Pakistan. mHealth supported systems can also prove to be a major breakthrough to improve and capture maternal and newborn child health outcomes.