Acknowledgements - UNICEF

1

Report

Childhood Vaccination Coverage Survey in Slums of Karachi & Hyderabad, Sindh Province of Pakistan

July 2020

Acknowledgements

This study was conducted with the technical support and oversight from UNICEF Immunization team Pakistan, with financial support of Gavi- the vaccine alliance and executed by Civil Society Human and Institutional Development Programme (CHIP) under the leadership of Provincial and Federal EPI programs. The report in hand presents the results of ‘Childhood Immunization Coverage Survey’ held in slums/underserved areas of Karachi and Hyderabad cities of Pakistan. Our sincere thanks to UNICEF for their technical support throughout the process to achieve the planned results. Our sincere thanks to UNICEF and WHO provincial and Country office colleagues, CSOs and expanded partners for their technical support and facilitation to complete this assignment. Special acknowledgement is extended to Federal and Provincial EPI Programs and District Department of Health who extended their leadership and fullest cooperation for the successful execution of the survey. Specific acknowledgement is also extended to all the respondents for participating in this study and adding

their valuable input to this discourse. It would not have been possible to present such in-depth, relevant and

reliable information without their cooperation.

Table of Contents

Abbreviations ................................................................................................................................................... 0

Executive Summary ......................................................................................................................................... 1

Chapter 1: Introduction .............................................................................................................................. 2

1.1 Demography ...................................................................................................................................... 2

1.2 Number of Slums ............................................................................................................................... 2

1.3 Status of Healthcare in Sindh ............................................................................................................ 2

1.4 Status of Immunization in Sindh ........................................................................................................ 3

1.5 Status of Immunization in Karachi & Hyderabad ............................................................................... 3

Chapter 2: Methodology ............................................................................................................................. 5

2.1 Study Design ..................................................................................................................................... 5

2.2 Study Sites ......................................................................................................................................... 5

2.3 Study Duration ................................................................................................................................... 5

2.4 Study Respondents ........................................................................................................................... 5

2.5 Sampling Procedures & Sample Size ................................................................................................ 6

2.6 Key Variables ..................................................................................................................................... 8

2.7 Data Collection Instruments............................................................................................................... 8

2.8 Operational Definitions ...................................................................................................................... 8

2.9 Data Analysis Techniques ............................................................................................................... 10

2.10 Monitoring Mechanism ..................................................................................................................... 10

2.11 Study Team And Training ................................................................................................................ 10

2.12 Objectives and Rationale of the Coverage Survey .......................................................................... 10

2.13 Study Limitations ............................................................................................................................. 11

Chapter 3: Status of Childhood Vaccination ......................................................................................... 13

3.1 Vaccination Coverage ...................................................................................................................... 13

3.2 Background Characteristics of Mothers ........................................................................................... 23

3.3 Background Characteristics of Households ..................................................................................... 24

Chapter 4: Conclusion ............................................................................................................................. 32

Chapter 5: Recommendations ................................................................................................................. 33

5.1 Human Centric Design for Demand Generation .............................................................................. 33

5.2 Targeted Strategy for Covering Zero Dose and Partially Vaccinated.............................................. 33

5.3 Channels of Communication............................................................................................................ 33

5.4 Team Work between LHWs & Vaccinators ..................................................................................... 33

5.5 Retention of Vaccination Card ......................................................................................................... 33

5.6 Other Alternatives ............................................................................................................................ 33

5.7 Accountability ................................................................................................................................... 34

Annex 1: Questionnaire for Household Coverage Survey ..................................................................... 35

Annex 2: Analysis of Household Coverage Survey ............................................................................... 39

Abbreviations

AIDS Acquired Immune Deficiency Syndrome

BCG Bacil le Calmette Guerin

CHIP Civi l Society Human and Institutional Development Programme

CI Confidence Interval

cMYP Country Multiyear Plan

CNIC Computerized National Identity Card

DEF Design Effect Factor

DPT Diphtheria, Pertussis and Tetanus

EOC Emergency Operation Centre

EPI Expanded Programme on Immunization

ESS Effective Sample Size

Hep B Hepatit is B

Hib Haemophilus Influenza type B

HIV Human Immune-deficiency Virus

HYD Hyderabad

ILR Ice-Lined Refrigerator

IMR Infant Mortali ty Rate

KCH Karachi

LEAD Leadership for Environment and Development

LHW Lady Health Worker

MDGs Mil lennium Development Goals

MICS Multiple Indicators Cluster Survey

MMR Maternal Mortali ty Rate

NDC National Disaster Consort ium

NGO Nongovernment Organisations

OPV Oral Polio Vaccine

PCV Pneumococcal Conjugate Vaccine

PDHS Pakistan Demographic Housing Survey

PKR Pakistani Rupee

PSLM Pakistan Social Living Measurement Survey

SATA Statistics and Data (Statistical Software Package)

SDG Sustainable Development Goals

SPSS Statistical Package for Social Sciences

TB Tuberculosis

TCV Typhoid Conjugate Vaccine

TT Tetanus Toxoid

UC Union Council

UN United Nations

UN-HABITAT United Nations Human Settlements Programme

UNHCR United Nations High Commissioner for Refugees

UNICEF United Nations Children Fund

WASH Water, Sanitation and Hygiene

WB World Bank

WHO World Health Organization

XDR Extensive Drug-Resistant

1

Executive Summary

A detailed survey was undertaken to determine the childhood vaccination coverage rates of children aged 12-23 months living in slums of Karachi1 and Hyderabad city. The coverage survey undertook assessment of 5,990 children through individual interviews of their mothers. Specific samples were calculated for slums of each district of Karachi and Hyderabad city according to the standard sampling guidelines issued in 2018 by World Health Organisation (WHO). The overall retention of vaccination card is less than 50% in slums of both cities (Karachi: 46% & Hyderabad: 26%). The coverage of BCG-OPV is higher in slums of Karachi (93%) compared to slums of Hyderabad (89%). In contrast the coverage of Penta 1 is same (83%) in the slums of two cities. The coverage of Penta 2 is lower in slums of Karachi (74%) compared to slums of Hyderabad (79%). Same trend can be seen for coverage of Penta 3 (Karachi: 67% & Hyderabad: 74%) and Measles 1 (Karachi: 59% & Hyderabad: 64%). The coverage assessment based on records2 shows less than 50% rates for all antigens in slums of both cities. The percentage of coverage rates for BCG-OPV, Penta 1 and Penta 2 are ranging in 40s in slums of Karachi while these percentages are ranging in 20s in the case of slums of Hyderabad for BCG, Penta 1, Penta 2. The percentage of coverage rates for Penta 3 and Measles 1 are even lower than 40s in slums of Karachi while even or lower than 20s in Hyderabad. Analysis of fully immunized children based on records + recall basis shows that slums of Karachi is slightly higher than the slums of Hyderabad. The percentages for fully immunized children drop to less than 30s in the case of slums of Karachi and less than 20s in the case of slums of Hyderabad when checked against records. Analysis of ratio of zero dose and partially vaccinated children are very interesting. The city with lower ratio of zero dose has higher ratio of partially vaccinated while city with higher ratio of zero dose has lower ratio of partially vaccinated. The slums of Karachi has lower ratio of zero dose (5%) compared to Hyderabad (10%) but the slums of Karachi has higher ratio of partially vaccinated (41%) compared to slums of Hyderabad (30%). The total sum of the two i.e. zero dose and partially vaccinators is higher in slums of Karachi (46%) compared to Hyderabad (41%). This report finds that although the coverage rates are higher on recall basis compared to records basis. But since 56% mothers are illiterate and 16% are educated between grades 1-5 the reliability of recall is limited. The living conditions of the children of slums are not only poor, but major disparities exist in terms of their accessibility to health, water and sanitation facilities. It is important to improve the access and demand of health and EPI services along with the targeted awareness raising campaigns so that children and women can be protected from vaccine preventable diseases.

1 Karachi city is comprised of six districts namely (i) Central, (ii) East, (iii) Korangi, (iv) South, (v) Malir (vi) West 2 Records refer to recording of coverage rates from the vaccination card.

Box 1: Major Inequities

Childhood Immunization 45% children are either zero dose or drop out 55% are fully immunized

Retention of Vaccination Card 41% children have vaccination cards.

Education Levels of Mothers 72% mothers are either illiterate or educated

between 1-5 grades. Housing Structures 50% or more residents of slums live in vulnerable

housing structures i.e. Kacha or Kacha/Pacca structures.

Livelihood 54% families rely on daily wage labor for livelihood.

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Chapter 1: Introduction

Sindh is one of the four provinces of Pakistan. By area, it is the third largest province of the country, and is second largest in terms of population. Sindh is the most urbanized province of Pakistan with around 52% population residing in the urban areas3. The province has the second largest economy in the country, after Punjab; whereas, the provincial capital Karachi is the largest city and houses headquarters of several multinational banks. Hyderabad, is the second largest city of the province. The rapid growth in the population of these cities has led to the emergence of the unplanned settlements known as slums (katchi abadi) in the cities with high population density and lack of permanent housing and basic services. Since the slums can vary from country to country and can be multidimensional and complex, the UN habitat has defined characteristics of slums, which included poor structures of houses, insecure residential status, inadequate access to safe drinking water and sanitation, and overcrowding4. Population living in slums simultaneously faces the increased risk of communicable and non-communicable diseases. The focus of this study is to investigate the vaccination coverage rates in the slums of Karachi and Hyderabad. The following section reviews the existing literature on coverage rates in the province of Sindh, specifically in the cities of Karachi and Hyderabad. 1.1 Demography The population of the Sindh province is 47.89 million; whereas, it is 14.9 million for Karachi5, a number, which is projected to increase to 18.7 million by 20256. The population density for the city of Karachi is approximately 6000 people per square kilometer. In the year 2016, the United Nations has ranked Karachi as the twelfth top megacity by size in the world, the number, which is expected to rise to seventh by 20307. The city is multicultural where 90% of the population consists of migrants from different backgrounds, with 5% growth rate. The largest ethnic group of the city is Muhajirs (Gujrati, Urdu, Marathi, Rajasthani, Konkani and Malbari Muslims)8. The religious demography of Karachi consists of majority of Muslims (80-90% Sunni, Shia 10-15%) and other religious groups including Christians and Hindus (3.6%)9. The most prevalent urban city problems include the increase in slum settlements, pollution, traffic jams, accidents and overcrowding. Likewise, public health problems are also prevalent in the city in relation to communicable and non-communicable diseases10. Hyderabad, on the other hand is the fourth-largest city in Pakistan with the population of 1.73 million. Hyderabad is the second most urbanized city of Sindh with around 80% of the people living in the cities11. The most commonly spoken language of the city is Urdu, followed by Sindhi, Punjabi and Saraiki. Due to a high rate of urbanization, the city has also seen a rapid growth in the growth of unplanned settlements. 1.2 Number of Slums Karachi and Hyderabad are key focus areas when it comes to unplanned urbanization and are the home to around 1300 slums in total. About 70% of these slums are situated in 18 towns of Karachi, whereas, the remaining 25-30% slums are located in four towns of Hyderabad12. There are more than 600 slums in Karachi. Karachi is also a home to the largest slum in Asia i.e. Orangi town with the estimated population of 2.4 million13.

1.3 Status of Healthcare in Sindh The results of a study on Primary Health Care in Karachi contend that among the sample (400 people) population of 8 largest slums,14 the most chronic non-communicable diseases that people are suffering from are diabetes (19%), kidney diseases (18%), liver issues (17%), 19% have hypertension (19%) and high levels

3 Noh, J. (2018). Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data. PLOS. 4 United Nations Human Settlements Programme (UN Habitat). Urbanization and Development: Emerging Futures; World Cities Report 2016. Nairobi, Kenya: UN Habitat; 2016. 5 Census of 2017 6 Sparkman, G. (2018). Challenges of slum life in Orangi Town, Karachi, Pakistan. Sparkman Center for Global Health. 7 Sparkman, G. (2018). Challenges of slum life in Orangi Town, Karachi, Pakistan. Sparkman Center for Global Health. 8 World Population Review, 2017 9 Central Intelligence Agency, 2018 10 Amer, K. (2013). Population explosion: Put an embargo on industrialisation in Karachi. Retrieved from https://tribune.com.pk/story/614409/population-explosion-put-an-embargo-on-industrialisation-in-karachi/ 11 Sparkman, G. (2018). Challenges of slum life in Orangi Town, Karachi, Pakistan. Sparkman Center for Global Health. 12 Khawar, H. (2019). A virulent strain. [online] DAWN.COM. Available at: https://www.dawn.com/news/1514595 [Accessed 15 Nov. 2019]. 13 Aleemi, A. and Khaliqui, H. (2019). Challenges and Patterns of Seeking Primary Health Care in Slums of Karachi: A Disaster Lurking in Urban Shadows. Asia Pacific Journal of Public Health, pp.1-12. 14 The slums are located in towns namely Orangi, Baldia Town, Gadap Town, Keemari, Korangi, Landhi, Gulshan Town, and North Nazimabad

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of cholesterol (16%). Only 11% people did not report any chronic diseases15. This is an indication of dire state of health-related affairs in slums. There is a need to investigate the causal factors associated with the occurrence of their chronic diseases. Sindh has been in limelight since the early 2019 due to the epidemic spread of HIV virus in the province. There are 26,041 people screened for HIV in the district Larkana of Sindh province. Out of those screened 751 people (2.9%) are reported to be tested positive for this infection (135 adults, 604 children and the age group of the 12 other patients is still unknown)16. The investigation into the case reported that in a local clinic of the district, a doctor has been using the same syringe on multiple patients and has not been using the syringe cutter. WHO has declared a Grade 2 emergency following this outbreak in the province as per the Emergency Response Framework. Apart from the uneventful eruption of the HIV cases, Sindh, particularly Karachi and Hyderabad, have been in the limelight due to the unprecedented spread of the XDR (extensive drug-resistant) typhoid cases since the last two years. Typhoid fever is extremely infectious and life threatening diseases and started emerging in 2016. The cases continued to spread in the country but the centre of the cases remained Sindh province between the periods Nov 1, 2016 to Dec 9, 2018. About 5274 cases were identified and 69% of the total identified cases were found in Karachi city, 27% in Hyderabad and 4% in other districts of Sindh Province. One of the major reasons of its spread is poor sanitation and unhygienic drinking water17. The same study stated above reveals that 33% of the residents in the total 8 investigated slums choose spiritual healers and Hakeem in case they fall sick. Trust on unqualified individuals for health related issues is an alarming sign and requires preventions and leads to aggravation of diseases. 27% of the residents reveal that they are dependent on Nongovernment Organisations (NGOs) and only 10% avail services of private clinics of government dispensaries. The reasons for choosing improper health facilities quoted by the slum residents have been ease of access, low cost and presence of waiting areas. Further studies on the status of healthcare in the province of Sindh reveal that apart from the occurrence of non-communicable diseases, there are communicable diseases prevalent in among the slum dwellers, which have been investigated in the following section. 1.4 Status of Immunization in Sindh The BCG coverage of Sindh province is 76%, whereas, it is 52% for Penta-3 for the children of age 12-23. Within the province, Dadu has the lowest coverage for BCG (57%) and Penta 3 (21%)18. The overall coverage rate of all the antigens for the Sindh province is at 43% as per 2014 statistics, which is almost double from 28% of 2006-2007. However, the rate for the province is still lower when compared to the other low and middle-income countries. The reasons identified for low coverage in the province are cultural factors, socioeconomic status, religious reasons, personal beliefs, social/peer environment, safety concerns and poor information on preventive healthcare.

1.5 Status of Immunization in Karachi & Hyderabad The vaccination coverage for Measles 1 in Karachi (65%) and Hyderabad (63%) are almost same. The study formulates that in the sample population of 400 people from 8 slums of Karachi, only 12% of the respondents reported the visits by LHWs. In the slum areas, where the level of education and awareness is already low, the absence of Lady Health Workers is an alarming sign, which demands immediate attention. The study further formulates that 75% of the sample population is not vaccinated for Hepatitis and Tetanus. Only 23% of the population has received vaccination19.

15 Aleemi, A. and Khaliqui, H. (2019). Challenges and Patterns of Seeking Primary Health Care in Slums of Karachi: A Disaster Lurking in Urban Shadows. Asia Pacific Journal of Public Health, pp.1-12. 16WHO, W. (2019). Pakistan: HIV outbreak in Sindh province. [online] Emro.who.int. Available at: http://www.emro.who.int/images/stories/pakistan/documents/who_donor_alert_pakistan_13_june_2019.pdf?ua=1 [Accessed 15 Nov. 2019]. 17 Centre for Infectious Diseases Research and Policy Dec 2018 18 MICS, S. (2014). MICS Survey. [online] Mics-surveys-prod.s3.amazonaws.com. Available at: https://mics-surveys-prod.s3.amazonaws.com/MICS5/South%20Asia/Pakistan%20%28Sindh%29/2014/Final/Pakistan%20%28Sindh%29%202014%20MICS_English.pdf [Accessed 15 Nov. 2019]. 19 Aleemi, A. and Khaliqui, H. (2019). Challenges and Patterns of Seeking Primary Health Care in Slums of Karachi: A Disaster Lurking in Urban Shadows. Asia Pacific Journal of Public Health, pp.1-12.

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Chapter 2 Methodology

Gender of Vaccinator – Major Excuse

Bareera aged 12 months and 2 days, lives in a small, dilapidated slum

named Kohistani Chowk located in Union Council Pahar Kunj. Umer Sadiq,

Bareera’s father, goes house by house to impart teachings of Quran to

children. Residing here for the past 07 years, their house is composed of 02

rooms in which a total of 11 people live. The 11 family members use a single

toilet. For domestic and drinking purposes, government water supply is

primarily relied upon. The colloquial language spoken in the house is

Pashto. The economic condition is despicable and is accustomed to facing

occasional debt. Aged 24, Bareera’s mother is illiterate and has not ever

received any formal education. She is completely unaware of childhood

vaccination and its significance. She says: “Bareera has not received any

vaccination due to her grandfather’s disapproval. He becomes infuriated by

such a proposition and is highly skeptical of the presence of men in

vaccination centers. Besides this, he says that no family member has time

available on his hands to take Bareera to vaccination center.”

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Chapter 2: Methodology

This part describes the detailed methodology adopted for the coverage survey. This methodology was designed in close consultation with the UNICEF Pakistan Country Office, UNICEF Pakistan Field Office and Provincial Expanded Programme on Immunization (EPI) Cell. The process was made participatory and engaging for having community driven perspectives. The methodology was finalized according to the security situation and local context.

2.1 Study Design The following four key activities were conducted for the purpose of this study (Figure 1).

2.2 Study Sites The study was conducted in the slums / underserved

areas located in two20 largest cities of Pakistan. The

administrative structure of Pakistan distributes the country into four provinces and Islamabad, Azad Kashmir and Gilgit Baltistan as federally administered areas. The provinces are further distributed into districts. Each district is distributed into multiple towns (tehsils), which are further distributed into union councils. Each union council has 5 to 15 villages/areas depending on the context and rural/urban settings in each province. Previously, the performance of the country against health indicators used to be assessed either at the provincial level and or at the district level. Gradually it has been realized that the performance needs to be monitored at the administrative unit level, which

is union council. 2.3 Study Duration This study was conducted in 2019 with different intervals. Overall it took about six months period to complete the survey. 2.4 Study Respondents Mothers of children aged 12-23 months old were study respondents. Questionnaire comprised of closed ended and open ended questions was utilised for holding individual interviews of mothers. 2.4.1 Inclusion Criteria Mothers of living children aged 12-23 months and residents of slums/underserved areas. 2.4.2 Exclusion Criteria Mothers of living children aged less than 12 months or more than 23 months and residents or non-residents of slums/underserved areas.

20 Karachi and Hyderabad

Figure 1: Key Activities in the Study

1. Sampling

4. Data entry,

analysis and

Reporting

2. Mapping of buildings

and children aged 12-

23 months

3. House-to-House

Interviews of Mothers

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2.5 Sampling Procedures & Sample Size The coverage survey was conducted to determine the childhood immunization rates by the study team. This background information about the households and respondents were also collected (Figure 2).

The correlations of the following three broader categories:

i. Vaccination coverage in children ii. Characteristics of the mothers and households iii. Vaccination coverage in children aged 12-23 months old

Were undertaken to comprehend the real reasons of high / low or no coverage rates in the slums / underserved areas. 2.5.1 Sampling Methodology This was conducted according to the methodology of World Health Organization (WHO). The following six points were utilized in calculating the sample size for this coverage survey. 1. Penta 3 coverage rates from 3rd party sources 2. Effective Sample Size (ESS) 3. Design Effect Factor (DEFF) 4. Estimation of number of children aged between 12 and 23 months 5. Calculation of inflation or no response 6. Steps for determining sample size and cluster 2.5.1a. Penta 3 Coverage Rates The city was taken as an independent stratum and Pakistan Demographic and Housing Survey 2017-18 was used for using Penta 3 coverage rates. The following coverage rates for Penta 3 were utilised for calculating the sample size.

Table 1: Penta 3 Coverage Rates for Each City

Cities Penta 3 Coverage Rates Sources for the Coverage Rates

Karachi 69% Admin source for the period Jan-June 2019

Hyderabad 54% MICS 2014

2.5.1b. Calculation of Effective Sample Size ESS was determined through expected coverage and desired precision level was set at 95 percent Confidence Interval (CI) as per Table B - 1, Page 118, WHO reference manual. 2.5.1c. Design Effect Factor Post measles campaign design effect factor calculated for the 3rd party survey 2018 was utilized as a basis for calculating the sample size. The following table presents the design effect utilised for calculating sample size for each city:

A. Vaccination Coverage in Children

A1. Vaccination Cards

A2. Fully Immunized

A3. Antigen wise Coverage

A4. Zero Dose

A5. Reasons of Zero Dose

A6. Prefered Channels of Communication

B. Characteristics of Mothers

B1. Age

B2. Educational Levels

B3. Employment

C. Characteristics of Households

C1. Language

C2. Housing Structures

C3. Access to Water

C4. Access to Toilets

C5. Primary Occupations

Figure 2: Key Elements for Background Information of Respondents

households

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Table 2: Post Measles Survey Design Effect

Cities Design Effect

Karachi 2.1

Hyderabad 3.4

2.5.1d. Estimation of Number of Children Aged between 12 and 23 Months The number of children aged between 12 and 23 months were determined by using the 3.5 percent of the total population are children between 0 and 1 year and 3.5 percent are between 1 and 2 years. The estimation of the number of 12-23 months old children was calculated as follows:

= Percentage of 12 – 23 months children in 100 household = 100 / 3 / 6.5 = 5 = This means that from every 5th to 6th house one child will be available = If the required # of children were not available in a cluster, new clusters were included and existing cluster was stopped.

2.5.1e. Calculation of Inflation or No Response Inflation or No Response factor from households was calculated by using the following formula mentioned in WHO manual. This factor is usually intended to include additional houses in case a child is not available at a set interval or has refused to participate. In order to overcome this, additional houses were also listed and profiled. The inflation or no-response factor was calculated as follows: No Response = 100 / 100 – P (Household Did not Respond)

= 100 / 100-5 = 1.05

2.5.1f. Calculation of Sample Size and Clusters Calculation of sample size was done once the DEFF and ESS, including No Response Inflation factor were all set. The following steps were undertaken to ascertain the sample-size: Total Completed Interviews = # of strata X ESS target from table B of WHO guidelines X DEFF21 Total Households to be visited to get the Target # of Households to be interviewed

= ESS X DEFF X household to find a child X no response inflation factor Number of Households to Visit per Strata = ESS X DEFF X household to find a child X no response inflation factor Number of Clusters = ESS X DEFF / Household to be interviewed per cluster Total Households to Visit per Cluster = Household to find a child X no response inflation factor X household to be interviewed per cluster. 2.5.2 Sampling Procedure: The slum was taken as a cluster. The following steps were undertaken during survey taking: a. City-wise lists of slums located in all urban towns were organized in an ascending order on the basis of

population; b. The random number for selecting slum was calculated by dividing the total slums by total clusters; c. After knowing the random number e.g. 2 or 3 or 4 or 5, every 2-5th slum of each town was picked up for

mapping and listing; d. Maps were prepared for each selected slum (cluster). The buildings including government schools were

numbered and marked. Maps of the areas/clusters/slums were prepared, and residential buildings were marked for the listing of the households;

e. Then by throwing the pencil on the map, the residential block was selected randomly; f. The selected block was listed, and number of children were also listed; g. List of minimum 80 to 150 houses were prepared;

21 Taken from Post Measles Campaign Analysis by WHO

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h. The total listed households were divided by 15 to calculate the random number for selecting a household for checking availability of children;

i. Listed households with the final random number were picked up for interview; and j. In case of unavailability of 15 children in the cluster, additional clusters were added. 2.6 Key Variables The key variables are grouped into four broader categories.

Table 3: Key Variables in the Study

A. Vaccination Coverage

Sample Size

Retention of Vaccination Cards

Fully Immunized Coverage

Antigen wise Coverage

Partially Vaccinated

Zero Dose

Reasons of Zero Dose

Information about Working of LHWs

Preferred Channels of Communication B. Characteristics of Mothers

Age

Educational Levels

Engagement in Livelihood C. Characteristics of Households

Commonly Spoken Language

Housing Structures

Access to Water

Household Toilet

Major Professions

D. Background Characteristics of Fully Immunized Vs. Zero-Dose

Illiteracy in Mothers

Kacha Housing Structures

Household Toilets

Daily Wage Workers

Debt Burden

2.7 Data Collection Instruments The data collection instrument was designed by the senior investigators and finalized in consultation with the UNICEF Pakistan officials. The instruments was pre-tested in order to ensure the consistency, appropriateness of language and sequencing of the questions. Based on the feedback from the pre-testing, the instruments was modified and rephrased, where necessary. These data collection instrument was not only translated into local languages but also culturally adopted, where necessary. The study instrument is attached in annexure. 2.8 Operational Definitions The operational definitions were defined based on the desk reviews as well as discussions with the health authorities.

2.8.1 Slums The definition of slums was reviewed from UN Habitat, Kachi Abadi Cell, Town Municipal Offices and Offices of Development Authority. Slums are a contiguous settlement where the inhabitants are characterized as having inadequate housing and basic services. A slum is often not recognized and addressed by the public authorities as an integral or equal part of the city. According to UN Habitat, the generic definition of a slum suggests that it is: ...a contiguous settlement where the inhabitants are characterized as having inadequate housing and basic services. A slum is often not recognized and addressed by the public authorities as an integral or equal part of the city (UN Habitat, 2010, p. 1322). Similarly, a slum household is defined as a group of individuals who live under the same roof that lacks one or more23 of the following conditions:

22 UN Habitat (2010), The Challenge of Slums: Global Report on Human Settlements 2003 23 This definition may be locally adapted for where some factors may be similar between the slums and majority of the society (UN Habitat).

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Limited access to improved water and sanitation

Weak housing structures

Insufficient living area

Uncertain about legal ownership of the residential area

2.8.2 Peri-Urban Slums Slums located at the periphery of urban areas that join the borders of cities and rural areas. 2.8.3 Underserved Areas Underserved Areas includes both planned residential areas with majority of the plastered housing structures. Underserved areas have one or more of the following conditions:

Low immunisation coverage or

High number of refusal

2.8.4 Expanded Programme on Immunization Expanded Programme on Immunization of the government of Pakistan for children and women of child-bearing age. 2.8.5 Kacha Housing Structure All walls and ceilings are made of mud, straws, bamboos or material other than cement, concrete and iron and are vulnerable to damage due to excessive rains, floods or earthquake etc. 2.8.6 Pacca Housing Structure All walls and ceilings are made of cement, concrete and iron. 2.8.7 Kacha-Pacca Housing Structure Walls are made of concrete and iron while ceiling is made of mud, straw or bamboo or vice versa. 2.8.8 Antigen A liquid medicine, which develops immunity in the body of an individual. 2.8.9 Fully Immunized Children aged between 12 and 23 months who have completed vaccination of all doses starting from BCG-OPV0, Penta 1, Penta 2, Penta 3, and Measles-1. 2.8.10 Partially Vaccinated Children aged between 12 and 23 months who have received some doses of vaccination but could not complete it according to age wise requirements. 2.8.11 Drop out Any child aged between 12 and 23 months who has received BCG+OPV0 and Penta 1 and Penta 2 but did not receive Penta 3 or Measles-1. 2.8.12 Zero Dose Children aged between 12 and 23 months who have not received any doses of vaccines including polio, which may protect children from vaccine preventable diseases. 2.8.13 Records Under two years of children whose vaccination cards containing record of their age wise doses administered are available in readable condition for any confirmation. 2.8.14 Recall Under two years of children whose record of vaccination is not presented on any paper or card at the time of the survey and mother shares the vaccination status based on her memory or recall. Under two years of children whose record of vaccination is not presented on any paper or card at the time of the survey and mother shares the vaccination status based on her memory or recall.

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2.8.15 Vaccine Preventable Diseases The vaccine preventable diseases for children aged between 0 and 23 months are prevented through offering basic vaccination. The names of these diseases are Childhood Tuberculosis, Poliomyelitis, Rotavirus Diarrhea, Pneumonia, Diphtheria, Pertussis (Whooping Cough), Tetanus, Hepatitis B (Hep B), Haemophilus Influenza type b (Hib) and Measles. 2.8.16 Antigens as part of Basic Vaccine The following antigens are administered to children aged between 0 and 15 months old with different age intervals:

Table 4: Vaccination Schedule

1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose 6th Dose

Immediately After Birth

6 Weeks 10 Weeks 14 Weeks 9 Months 15 Months

BCG+OPV0 OPV 1, Rota 1, Pneumococcal Conjugate Vaccine (PCV) 1, Penta 1

OPV 2, Rota 2, PCV 2, Penta 2

OPV 3, Rota 3, PCV 3, Penta 3

Measles-1 Measles-2

2.9 Data Analysis Techniques Systematic approach was adopted for cleaning, and verification and further entering of data in excel sheets as per the variables defined for this study. The data was analyzed by the Data Manager in Statistical Package for Social Sciences (SPSS) and Statistics and Data (STATA). The processed data is interpreted through tabular and graphical presentation required for quantitative analysis. 2.10 Monitoring Mechanism For the purpose of this study, timely review and rigorous monitoring system was put in place to ensure there were no detractions. This included engagement of a full-time team dedicated to holding survey, timely submission of data, physical verification and further cleaning process of the data, and assignment for each team member. The monitoring ensured the following:

Verification of data either through telephonic correspondence or physical on-field visits Supportive supervision and daily review of field performance Trouble shooting in case of problems Review of survey forms to ensure that no information was missed or fake or contradictory

2.11 Study Team And Training A three-tiered team was engaged in childhood vaccination coverage in slums / underserved areas.

The first tier of team comprised of a team leader, survey supervisors and data collectors. The team leader provided overall guidelines and end-to-end management of the process, the supervisors extended supportive supervision and monitoring of the data collection and ensured quality standards while surveyors collected the data from the field through physical visits, group discussions and individual interviews. The 2nd tier of the team consisted of data validation, cleaning, entry and analysis. The 3rd tier of the team comprised report writers responsible for undertaking desk researches and interpreting the results in an effective manner. The training of study teams was conducted by the professionals prior to commencing data collection activities that includes study objectives, basic concepts on healthcare and immunization services, data collection, ethical considerations as well as confidentiality. In addition, they were trained on data entry processes (i.e. validation and cleaning before their final consolidation). 2.12 Objectives and Rationale of the Coverage Survey Line lisitng and profiling of slums was done in 2017 with the aim to support process for increasing coverage in slums. Soon after the profiling of slums, it was realized that statistics about current status of immunization in the slums and underserved areas would be even more helpful to reach zero dose, drop out and under

Figure 3: Study Team Composition

1. Team Leader Supervisors

Data Collectors

Data Entry Operators

2. Data Validation Team

Data Assistant

3. Report Writer Data Analyst

Graphic Designer

11

vaccinated children. Thus, in order to create a baseline on status of immunization, background charateristics of mothers and household, it was felt important to undertake a dedicated coverage assessment exercise in slums of ten cities including Faisalabad, Gujranwala, Lahore, Multan, Rawalpindi, Islamabad, Quetta, Peshawar, Karachi and Hyderabad. 2.13 Study Limitations Although the survey was conducted with a highly reliable team to know the status of immunization in children aged 12-23 months old and the methodology was designed according to the latest sample calculation and procedures, but the results may have some limitation explained below: 2.13.1 The status of vacicnation was not tirangualted with the data available in fixed EPI facilties hence the

survey records for recall basis may have some variations; 2.13.2 The coverage survey was conducted only with mother living in slums and underserved areas. Majority

of the mothers were either illiterate or have very low levels of education. The responses may have some understanding gaps;

2.13.3 Since the majority of the respondents of coverage survey were illiterate mothers therefore status of vacicnation on recall basis have limited relaibaility;

2.13.4 Since majority of the mothers of zero dose children were illiterate therefore reasons of zero dose may have missed some more aspects.

12

Chapter 3 Childhood Vaccination

13

Chapter 3: Status of Childhood Vaccination

This chapter presents the analysis of vaccination coverage rates of children aged 12-23 months. The coverage rates are correlated with the social characteristics of households and profile of mothers. This chapter comprehensively covers the following variables: 3.1 Vaccination Coverage 3.2 Characteristics of Mothers 3.3 Characteristics of Households 3.4 Background Characteristics of Fully-Immunized Vs. Zero-Dose

3.1 Vaccination Coverage 3.1.1 Sample Size 5,990 children (12-23 months) of 5,970 mothers living in 5,962 households of slums were included in the sample. Sample size of each district of Karachi and Hyderabad was calculated. The largest sample size was for Hyderabad (1365) and smallest sample size was for District Korangi (568). These households have a total of 40,443 family members with an equal number of males and females (Table 47 Annex 2). The average family size is 8 persons per house. Comparison of family size across districts reflects, highest family size (8) in Hyderabad, while lowest family size (6) in District Korangi, South and West. While District Central and East, Malir have an average family size of 07 (Table 48, Annex 2). 99.7% mothers have one child aged 12-23 months while only 0.3% mothers have two children aged 12-23 months at the time of the survey (Table 39, Annex 2). 3.1.2 Retention of Vaccination Cards Only 41% children have vaccination cards. City wise comparison reflects that retention of vaccination card is high in slums of Karachi (46%) compared to slums of Hyderabad (26%).

District wise comparison reflects highest retention of vaccination card in slums of District West (63%) and lowest in slums of Hyderabad (26%). Retention of vaccination card in slums of majority of the districts of Karachi is above 40% except slums of one District Malir (30%). The gender lens on the card retention confirms that it is higher for boys (53%) and lower for girls (47%). The card retention pattern for boys is almost same across all districts except for District Central where an equal number of boys and girls have vaccination card (50% for each gender). In Hyderabad, card retention for boys is 54% while it is 46% for girls (Table 3, Annex 2). 24Unavailability of card is highly linked to the lack of awareness regarding the importance of vaccination cards as 81% of mothers stated that card is either lost or torn or thrown. While 5% mothers received no vaccination card and this percentage is highest in District East (12%) (Table 4, Annex 2).

24 This question was asked only in Karachi and not in Hyderabad

Table 5: Units of Analysis in the Survey

Districts Households Mothers Children

Central 661 666 668

East 843 843 847

Korangi 567 568 568

Malir 842 842 845

South 842 843 848

West 842 843 849

Sub Total Karachi 4597 4605 4625

Hyderabad 1365 1365 1365

Grand Total 5962 5970 5990

26%30%

43% 43% 44%

54%

63%

Hyderabad Malir Korangi South East Central West

Figure 4: Retention of Vaccination Card

46%

26%

41%

Karachi Hyderabad Total

Figure 5: Retention of Vaccination Card

14

3.1.3 Fully Immunized Children25 Based on records and recall basis, overall 55% children in slums are fully immunized. The percentage of fully immunized children is higher in slums of Hyderabad (59%) compared to slums of Karachi (54%). District wise comparison indicates slums of Hyderabad at the top (59%) and slums of District Malir and Central (50%) at the lowest level. The coverage rates for fully immunized children in slums stands below 60% in all districts with very minor variations.

Overall, coverage rates for fully immunized (27%) when analysed against records highlight alarming situation. Slums of Hyderabad (18%) report less than 20% while slums of Karachi reflect less than 30% coverage rates. District wise comparison shows that slums of all districts below 50% with highest coverage in slums of District West (42%) and lowest coverage in slums of District Malir (16%) and Hyderabad (18%). The gender lens on fully immunized children found 53% fully immunized boys compared to only 47% fully immunized girls. Slums of Karachi and Hyderabad have same situation for fully immunized girls and boys.

Significant gender variation is found in District Central where 57% boys are fully immunized as compared to 43% girls. District Malir is the only district where 50% boys and 50% girls are fully immunized. Highest percentage of fully immunized boys is found in District Central and District East i.e. 57% and 55% respectively.

25 Only those children are included who have received all antigens up-to Measles 1.

50%

50%

53%

56%

57%

59%

59%

Malir

Central

East

West

Korangi

South

Hyderabad

Figure 6: Fully Immunized (Records+Recall)

54%

59%

55%


Figure 7: Fully Immunized (Records+Recall)

16%

18%

27%

30%

31%

32%

42%

Malir

Hyderabad

East

Korangi

South

Central

West

Figure 8: Fully Immunized (Records)

29%

18%

27%


Figure 9: Fully Immunized (Records)

53% 53% 53%

47% 47% 47%


Figure 11: Gender Lens on Fully Immunized (Records+Recall)

FICs Boys FICs Girls

50%

51%

52%

53%

54%

55%

57%

50%

49%

48%

47%

46%

45%

43%

Malir

West

Korangi

Hyderabad

South

East

Central

Figure 10: Gender Lens on Fully Immunized (Records+Recall)

FICs Girls FIC Boys

15

3.1.4 Antigen wise Coverage 3.1.4a. BCG Overall BCG coverage on records and recall basis is 92%. Slums of Karachi with 93% coverage have slightly higher rates compared to slums of Hyderabad (89%). District Malir (88%) stands out for having lowest coverage rates for BCG. Three districts of Karachi namely South (97%), West (95) and Korangi (95%) have 95% or higher coverage rates for BCG.

Overall BCG Coverage on record basis is 41% for the slums of both cities while individual comparison reflects slums of Karachi (45%) have higher coverage rates for BCG compared to Hyderabad (26%). District wise comparison highlight four categories i.e. districts having BCG coverage rates ranging in 20s (Malir & Hyderabad), 40s (Korangi, South & East), 50s (Central) and 60s (West). Highest drop in coverage rates is found in Hyderabad (63%) and Malir (59%). Lowest drop is found in District West (34%). 3.1.4b. Penta 1 Based on records and recall basis, the coverage for Penta 1 is recorded at 83% and it stands at same level in slums of Karachi (83%) and Hyderabad (83%). District wise comparison found highest coverage in slums of District South (86%) and East (86%) and lowest coverage in slums of District Malir. The coverage of Penta 1 remains in 80s in slums of all districts including Hyderabad except in District Malir (75%).

88%

89%

91%

93%

95%

95%

97%

Malir

Hyderabad

East

Central

Korangi

West

South

Figure 12: BCG Coverage (Records+Recall)

93%

89%

92%


Figure 13: BCG Coverage (Records+Recall)

26%

29%

42%

43%

43%

53%

61%

Hyderabad

Malir

East

South

Korangi

Central

West

Figure 14: BCG Coverage (Records)

45%

26%

41%


Figure 15: BCG Coverage (Records)

75%

83%

84%

85%

85%

86%

86%

Malir

Hyderabad

West

Central

Korangi

East

South

Figure 16: Penta 1 Coverage (Records+Recall)

83% 83% 83%


Figure 17: Penta 1 Coverage (Records+Recall

16

The coverage of Penta 1 came down from 83% to only 39% when checked against records. Highest drop of Penta 1 coverage is found in Hyderabad where coverage came down from 83% to 25% only when checked against records. District wise comparison reflect similar trend and highest drop is found in two districts (Hyderabad and Malir) and lowest drop is found in District West and District Central. 3.1.4c. Penta 2 Overall coverage rates for Penta 2 stands at 75% with relatively higher coverage in slums of Hyderabad (79%) compared to slums of Karachi (74%).

District wise comparison reflects very different result for slums of Hyderabad (79%) where it reports better results in comparison to other districts while slums of District Malir remains at bottom of the graph (64%). Percentage of Penta 2 coverage remains in 70s except for slums of District Malir.

The record wise analysis of Penta 2 coverage brought back slums of Hyderabad (24%) to the bottom of the graph together with slums of District Malir (23%). Slums of all districts report less than 50% coverage for Penta 2 except for slums of District West (54%). 3.1.4d. Penta 3 Based on records+recall basis, overall Penta 3 coverage is 69% for slums of both cities with higher coverage in slums of Hyderabad (74%) compared to slums of Karachi (67%). District wise comparison reflect Malir (58%) at the bottom and Hyderabad (74%) at the top which is interesting. The percentages for Penta 3 coverage is ranging between 60s and 70s for majority of the districts except for Malir (58%).

43%

25%

39%


Figure 19: Penta 1 Coverage (Records)

25%26%

41%41%41%

50%59%

Hyderabad

Korangi

South

West


74%

79%

75%



64%

74%

75%

75%

79%

79%

79%

Malir

Korangi

East

West

South

Central

Hyderabad


40%

24%

36%



23%

24%

38%

38%

39%

47%

54%

Malir

Hyderabad

Korangi

East

South

Central

West


17

Overall Penta 3 coverage rates stands at 33% with slums of Karachi (36%) having slightly higher coverage compared to slums of Hyderabad (22%). The district wise comparison highlights Penta 3 coverage is below 50% when checked against records in slums of all districts with highest coverage in slums of District West (49%) and lowest coverage in slums of District Malir (20%). Slums of Hyderabad (22%) comes down at the bottom together with slums of District Malir (20%) with very low coverage rates for Penta 3. 3.1.4e. Measles 1 On records and recall basis, coverage for Measles 1 stands at 60% with slums of Hyderabad reporting slightly higher coverage than slums of Karachi (59%). The district wise comparison reflects slums of Hyderabad (64%) at the top and slums of District Central (54%) at the bottom of the graph. Slums of all districts report less than 65% coverage rates for Measles 1 except three slums of districts (East, Malir and Central), which report less than 60% coverage rates.

20%

22%

34%

34%

35%

42%

49%

Malir

Hyderabad

Korangi

East

South

Central

West


36%

22%

33%



54%

55%

58%

60%

61%

62%

64%

Central

Malir

East

Korangi

West

South

Hyderabad

Figure 28:Measles 1 Coverage (Records+Recall)

59%

64%

60%


Figure 29: Measles 1 Coverage (Records+Recall)

58%

65%

66%

69%

72%

73%

74%

Malir

East

Korangi

West

Central

South

Hyderabad


67%

74%

69%



18

Analysis of Measles 1 based on record basis stands at 29% with slums of Karachi (33%) reporting slightly higher coverage than Hyderabad (19%). The district wise comparison brought slums of Hyderabad (19%) at the bottom together with slums of District Malir (19%). Slums of majority of the districts report Measles 1 coverage below 37% except for slums of District West (47%), which is slightly higher than other districts but remains below 50%. 3.1.4f. Drop out Rates The comparison of drop out rates from BCG to Penta 3 and BCG to Measles 1 reflect higher percentage of drop out for Penta 3. Overall, the drop out rate from BCG to Penta 3 is 35% while the drop out rate from BCG to Measles 1 is 26%. The high percentage of drop out could be due to multiple reasons including weak follow up and rapid movement of families from one place to another. 3.1.5 Partially Vaccinated Based on records and recall, overall 38% children are partially vaccinated with slightly higher percentage in Karachi (41%) compared to Hyderabad (30%). The district wise comparison reflects that District Central (44%) having highest percentage of partially vaccinated while Hyderabad (30%) having lower percentage. The most alarming sign is that percentage of partially vaccinated children is above 30% in all districts with three districts (Central, East, West) having even more than 40% partially vaccinated.

It is important to know that slums of districts with low percentage of partially vaccinated children have high percentage of zero dose children, which reflects that some slums of the districts have issues of starting the vaccination and some slums of the districts have issues of continuing the vaccination. For example slums of Hyderabad has 30% partially vaccinated and 10% zero dose which comes to 40%. Similarly the slums of District West have 41% partially vaccinated and only 3% zero dose children. Overall, gender lens on partially vaccinated does not highlight major variations. Slums of Karachi have same percentages of partially vaccinated for both genders while slums of Hyderabad have slightly higher percentage of partially vaccinated boys.

19%

19%

30%

32%

32%

36%

47%

Hyderabad

Malir

East

South

Korangi

Central

West

Figure 30: Measles 1 Coverage (Records)

33%

19%

29%


Figure 31: Measles 1 Coverage (Records)

30%

39%

39%

39%

41%

42%

44%

Hyderabad

Korangi

Malir

South

West

East

Central

Figure 32: Partially Vaccinated (Records+Recall)

41%

30%

38%


Figure 33: Partially Vaccinated (Records+Recall)

19

The percentage of partially vaccinated boys are higher in slums of four of the seven districts while it is equal for one District West and lower for two districts East and Central. 3.1.6 Zero Dose Overall 7% (391) children have not received any antigen hence are zero dose with slums of Hyderabad (10%) reporting higher percentage of zero dose compared to Karachi (5%). The district wise variations indicate that higher share of zero dose children in District Malir (11%) and Hyderabad (10%); whereas the lower share of zero dose in District South (2%).

The gender lens on zero dose reflects that 54% of the zero dose children are boys and 46% zero dose are girls. The variation is more noticeable in District South where 71% zero dose are boys compared to only 29% zero dose girls. However in contrast only District East has higher share of zero dose girls (53%) as compared to zero dose boys (47%) (Table 5, Annex 2).

3.1.7 Reasons of Zero Dose Majority of the reasons of zero dose children are related to unawareness of importance of vaccination. Another significant proportion (36%) reports non-permission from their respective family members for not getting their children vaccinated. Four reasons emerge as significant barriers for vaccination i.e. (i) vaccination causes more diseases (ii) non permission by family decision makers (iii) families do not have time for vaccination and (iv) fear of injection. The percentages assign to each reason shows that except non-permission (36%), all other reasons are related with the low awareness on importance of vaccination.

2%

3%

5%

5%

6%

10%

11%

South

West

East

Korangi

Central

Hyderabad

Malir

Figure 36: % of Zero Dose Children

5%

10%

7%


Figure 37: % of Zero Dose Children

1%

2%

3%

3%

4%

7%

16%

17%

36%

41%

Unfriendly EPI

High Transport Cost

Time wastage

Child is Sick

Unaware of Vaccination Timings

Unaware of Vaccination Point

Fear of Injection

No Time

No Permission

Cause Diseases

Figure 38: Overall Reasons of Zero Dose

50%

55%

51%

50%

45%

49%

Karachi

Hyderabad

Total

Figure 35: Gender wise Partially Vaccinated

(Records+Recall)

Girls Boys

48%

48%

50%

52%

52%

52%

55%

52%

52%

50%

48%

48%

48%

45%

Central

East

West

Korangi

Malir

South

Hyderabad

Figure 34: Gender wise Partially Vaccinated

Records+Recall

Girls Boys

20

Although the three top rated causes in the two cities i.e. ‘(i) no permission (ii) causes more diseases (iii) no time for vaccination’ are common but their intensity varies. For example non permission is an intense issue in slums of Karachi while unawareness of importance of vaccination is predominant issue in slums of Hyderabad as 53% mothers think that vaccination causes more diseases.

The top reasons of zero dose in the overall graph for two cities are analysed for each district and found interesting reflections. Non-permission appears as the top most reason of zero dose in four of the six districts of Karachi. The intensity of non-permission is found very high in two districts of Karachi namely Korangi (70%) and Central (63%). ‘Fear of injection’ appears very strongly in slums of two of the four districts namely Korangi (30%) and South (24%). Similarly ‘vaccine causes more diseases’ also found very high in three of the six districts namely Korangi (41%), Malir (46%) and West (37%).

0%

0%

1%

1%

2%

3%

14%

16%

25%

53%

Unfriendly EPI

Child is Sick



High Transport Cost

Time wastage

Fear of Injection

No Permission

No Time

Cause Diseases

Figure 40: Reasons of Zero Dose in Hyderabad Slums

3%

16%

22%

46%

No Time for Vaccination

Fear of Injection

Cause Diseases

No Permission

Figure 41: Reasons of Zero Dose in District Central

16%

24%

45%

46%

Fear of Injection


No Permission

Cause Diseases

Figure 43: Reasons of Zero Dose in District Malir

11%

11%

22%

42%

Fear of Injection


Cause Diseases

No Permission

Figure 42: Reasons of Zero Dose in District East

4%

30%

41%

70%


Fear of Injection

Cause Diseases

No Permission

Figure 45: Reasons of Zero Dose in District Korangi

5%

24%

24%

29%


Cause Diseases

Fear of Injection

No Permission

Figure 46: Reasons of Zero Dose in District South

2%

2%

2%

5%

5%

10%

13%

17%

35%

48%

Unfriendly EPI

High Transport Cost

Time wastage

Child is Sick



No Time

Fear of Injection

Cause Diseases

No Permission

Figure 39: Reasons of Zero Dose in Karachi Slums

7%

7%

37%

63%

Fear of Injection


Cause Diseases

No Permission

Figure 44: Reasons of Zero Dose in District West

21

3.1.8 Information about Working of LHWs Only 42% mothers are found aware of working of LHWs while city wise comparison reflect that almost all women in Hyderabad are aware of working of LHWs while in Karachi only a small percentage (25%) of mothers are aware of working of LHWs in their respective areas.

District wise comparison highlight that besides Hyderabad 95% mothers in District East are also aware of working of LHWs in comparison to very low percentage of mothers of District West (10%), District Korangi (15%) and District South (16%) respectively. Of those who are aware of working of LHWs, believe that they provide general health education to women. Only 5% mothers report that LHWs are engaged in supporting vaccinators and 1% report that LHWs provide information about vaccination (Table 42, Annex 2).

3.1.9 Vaccine Prevent Diseases – Mothers’ Knowledge Less than half of the mothers (43%) believe that vaccine prevent their children from diseases. City wise comparison shows no major difference between slums of Karachi (43%) and Hyderabad (44%).

District wise comparison reflect lowest percentage of mothers living in slums of District Malir (32%) and District East (38%) having awareness that vaccine prevent their children from diseases. District South and District Korangi appear relatively better where about half of the women perceive vaccine prevent diseases which is a positive sign. 3.1.10 Perception of Mothers - EPI Facility is Accessible Only 12% mothers consider EPI facility is accessible for them as the distance is easily manageable. City wise comparison highlight that this percentage is very low for Hyderabad (2%) compared to Karachi (15%).

25%

99%

42%


Figure 48: Information about Working of LHWs


10%

15%

16%

29%

39%

43%

99%

West

Korangi

South

Malir

Central

East

Hyderabad

Figure 47: Information about Working of LHWs

32%

38%

44%

44%

47%

48%

50%

Malir

East

Hyderabad

Central

West

Korangi

South

Figure 49: Vaccine Prevent DiseasesMothers' Perception

43%

44%

43%


Figure 50: Vaccine Prevent DiseasesMothers' Perception

22

District wise comparison reflect that less than quarter of the mothers living in slums of all districts perceive that EPI facility is accessible for them. Lowest percentage of mothers in slums of Hyderabad and Malir report that EPI facility is accessible to them while this percentage is relatively better for Korangi where 21% mothers in slums report that EPI facility is accessible to them.

3.1.11 Commonly Utilized Vaccination Services Overall 82% of the families utilize health facility for getting the vaccination of their children. City wise comparison reflects that greater percentage of families in slums of Karachi (83%) utilize health facility for the vaccination of their children compared to families in slums of Hyderabad (77%).

District wise comparison reflects greater variations e.g. majority of the families of three districts namely Korangi (93%), West (90%) and South (90%) utilize health facilities for the vaccination of their children compared to District East where only 68% mothers utilize health facilities for the vaccination of their children. A significant percentage of mothers in District East (31%) utilize outreach services and in District Central (30%) utilize private doctors for getting vaccination of their children. 3.1.12 Preferred Channels of Communication Three channels namely television, health workers and any new source other than conventional have emerged as the most preferred channel of communication amongst all. Overall, 54% mothers prefer to receive information about childhood vaccination through Television and 52% mothers prefer to receive information about childhood vaccination from a new source other than conventional. A small percentage (35%) prefers health workers for receiving information about childhood vaccination. City wise comparison, indicate 86% mothers in slums of Hyderabad prefer television for receiving information in comparison to less than half of the mothers (44%) of slums of Karachi. About 84% mothers from slums of Hyderabad also prefer health worker for receiving information. In contrast, a small percentage of mothers from slums of Karachi (19%) prefer health worker for receiving information.

2%

11%

12%

14%

16%

16%

21%

Hyderabad

Malir

Central

East

South

West

Korangi

Figure 51: Perception of MothersEPI Facility is Accessible

15%

2%

12%


Figure 52: Perception of MothersEPI Facility is Accessible

12%

2%

21% 83%

3%11% 22% 77%

9%3%

21% 82%

Private Doctor LHW Outreach EPI Facility

Figure 54: Commonly Utilized Vaccination Service


16%30%

3% 3% 10% 10% 1%

7%2%

11% 0% 1% 1% 0%

31% 29%

22%21% 16% 16% 17%

68% 76%77%

83% 90% 90% 93%

East Central Hyderabad Malir South West Korangi

Figure 53: Commonly Utilized Vaccination Service

Private Doctor LHWs Outreach EPI Facility

23

District wise comparison reflects different preferences of Hyderabad and other districts of Karachi. Slightly greater than half of the mothers of slums of Karachi in three of the six districts of Karachi, prefer television for receiving information while a significant percentage of mothers in slums of five of the six districts of Karachi prefer to have information from a new source. 3.2 Background Characteristics of Mothers In order to comprehend the real reasons of low or no coverage, it important to know the background characteristics of mothers. Three major variables i.e. mother’s age, educational levels and engagement in livelihood activities. 3.2.1 Age Overall majority (58%) of the mothers are 20-29 years of age with 37% are 30-39 years of age and very small percentage of mothers are under 19 years (3%) and over 40 years (2%).

District wise comparison reflect the same trend with minor variations. The highest variation is found in District West where 20-29 years of age mothers are 64% while lowest variation is found in District Central where 52% mothers are 20-29 years of age. Three districts namely Korangi, East and Central report relatively greater percentage (3%) of younger mothers. 3.2.2 Educational Levels Overall 56% mothers are illiterate and 16% are educated between 1-5 grades. Only 20% mothers are educated between 6-10 grades. A small percentage (8%) have education between 11 grades and above. City wise comparison reflects higher percentage of illiterate mothers in Hyderabad (72%) compared to Karachi (51%). Relatively a greater percentage of mothers in Karachi (26%) are educated between 6-10 years of

schooling compared to Hyderabad (4%) where less than 20% are educated between 6-10 years of schooling.

3%

3%

2%

2%

3%

3%

2%

52%

58%

57%

58%

62%

62%

64%

43%

37%

39%

39%

34%

34%

32%

2%

2%

2%

1%

1%

1%

2%

Central

East

Hyderabad

Malir

South

Korangi

West

Figure 57: Age Range of Mothers

14-19

20-29

30-39

40+

3%

2%

3%

59%

57%

58%

36%

39%

37%

2%

2%

2%

Karachi

Hyderabad

Total

Figure 58: Age Range of Mothers

14-19

20-29

30-39

40+

22%34%

38%50% 57% 63% 86%1%

0.40%10%

6% 3% 9%12%

4%

2%15%

16% 23%28% 11%

2%

3%3%

5%5%

8% 8%

19%

5%37%

18%11% 21%

84%82% 74%

72%50% 56%

45%

15%

Figure 55: Prefered Channel of Communication

TV Radio Poster/Billboard Leaflet Health Worker Others

44% 5%

15%4%

19%

63%

86% 12%11%

8% 84%

15%

54% 7% 14% 5% 35%52%

TV Radio Posters Leaflet HealthWorker

Others

Figure 56: Prefered Channel of Communication


24

District wise comparison reflects highest ratio of illiterate mothers in Hyderabad (72%) and District Malir (66%) and lowest percentage of illiterate mothers in three districts namely Central (45%), South (44%) and West (43%). Highest percentage of mothers educated between 6-10 years of schooling is found in District South (33%) and District West (31%). 3.2.3 Engagement of Mothers in Livelihood Only a small percentage (7%) of mothers are engaged in livelihood activities while 93% mothers are serving as homemakers. City wise comparison reflects that greater percentage of mothers in slums of Karachi (8%) are engaged in livelihood activities compared to slums of Hyderabad (5%).

District wise comparison reflects greater percentage of mothers in slums of District East (16%) and District Central (9%) engaged in livelihood activities compared to very low percentage of mothers in slums of District Malir (2%) and Hyderabad (5%) and District Korangi (5%). 3.3 Background Characteristics of Households The background characteristics of households were checked to know the family background, living conditions and economic pressures. Five major variables were analyzed i.e. duration of residence to know the status of migrated families, language spoken to know the ethnic background, housing structures, access to water and toilets, major professions.

3.3.1. Duration of Stay in Slums Only 10% of the families are found in slums that got settled here for one year of less timeframe. Majority of the families (41%) are living in slums for 6-15 years. About quarter of the families are living in slums for 2-5 years or for more than 15 years depending on the location. City wise comparison reflects that families living in slums for one year or less are in greater percentage in slums of Karachi (12%) compared to families in slums of Hyderabad (4%). Long terms settlers i.e. six years plus are in greater percentage in Hyderabad (84%) compared to Karachi (62%). District wise comparison highlight five of the seven districts having more than 10% families living in slums for one year or less timeframe. Amongst these five, District East emerge as having highest percentage (17%) of families living here for one year or less time frame. Over half of the families across all districts are living herewith for 5 years and more time frame.

43%

44%

45%

52%

55%

66%

72%

14%

17%

13%

15%

15%

16%

17%

31%

33%

30%

27%

22%

15%

4%

12%

7%

12%

6%

8%

3%

7%

West

South

Central

Korangi

East

Malir

Hyderabad

Figure 59: Years of Schooling Attended by Mothers

Illiterate

1-5 Years

6-10 Years

11 YearsPlus 51%

72%

56%

15%

17%

16%

26%

4%

20%

8%

7%

8%

Karachi

Hyderabad

Total

Figure 60: Years of Schooling Attended by Mothers

Illiterate

1-5 Years

6-10 Years

11 YearsPlus

2%

5%

5%

6%

7%

9%

16%

Malir

Hyderabad

Korangi

West

South

Central

East

Figure 61: Mothers Engaged in Livelihood Activities

8%

5%7%


Figure 62: Mothers Engaged in Livelihood Activities

25

The reasons of families living in slums for one year or less timeframe are mostly temporary displacement from their original area of residence, search for better jobs and other unspecified reasons. Overall, families living in slums due to temporary displacement is greater (4%) compared to being there for better job opportunities (3%). City wise comparison reflects that slums of Karachi have greater percentage of temporary displaced families while slums of Hyderabad has greater percentage of people looking for better job opportunities. District wise comparison reflect that the proportion of temporary displaced families are higher in District Central (6%) and District West (6%) while these are very low in Hyderabad (1%) and District Malir (1%). The job holders are higher in two districts Central (8%) and East (7%) compared to other five districts where percentage of job holders ranges between 1-2%. 3.3.2 Commonly Spoken Language Overall Sindhi (24%) and Urdu (22%) are the commonly spoken languages while Pashto is spoken in 14% households. City wise comparison reflects that Hyderabad (44%) has greater share of Sindhi speaking households compared to Karachi (18%). The percentage of Urdu speaking is almost same in Karachi (22%) and Hyderabad (21%). Hyderabad has very low number of households speaking other languages such as Pashto (3%), Punjabi (4%) and Balochi (4%). Slums of Karachi have more diversity of spoken languages. Pashto is spoken by 17%, Punjabi is spoken by 13%, Balochi is spoken by 12% households.

14% 17% 11% 9% 9% 14%4%

25%27%

29%24% 26%

28%

12%

30%38% 49%

52% 47% 30%

40%

31%18% 11% 15% 18%

28%44%

Central East Korangi Malir South West Hyderabad

Figure 63: Years of Stay in Slums

One Year or Less 2-5 Years 6-15 Years 15 Years Plus

12% 26%42%

20%

4% 12% 40% 44%

10% 23% 41% 26%

One Year or Less 2-5 Years 6-15 Years 15 Years Plus

Figure 64: Duration of Stay in Slums


3%4% 4%

2%1% 1%

3%4% 4%

Better Job Displaced Other Reason

Figure 66: Reasons of Shorter Stay in Slums


8% 7%

1% 1% 2% 1% 2%

6%5%

4%2%

5% 6%1%

0% 5%

6%

6%

2%

7%

1%


Figure 65: Reasons of Shorter Stay in Slums

Better Job Displaced Other Reason

26

District wise comparison reflects that percentage of Urdu speaking households living in slums of six districts of Karachi ranges between 14% to 32%. While Sindhi speaking are higher in District Hyderabad (44%) and District Malir (40%). Pashto and Punjabi also emerge as third most commonly spoken language. The percentage of Pashto speaking households ranges between 3% to 23% in all districts while percentage of Punjabi speaking ranges from 4% to 19% in all districts. 3.3.3 Housing Structures Overall majority of the families of slums are living either in kacha or kacha-pacca housing structures. Less than half of the families report living in Pacca housing structures. City wise comparison reflect 58% families living in either kacha or kacha-pacca housing structures in Hyderabad compared to 52% families of slums in Karachi.

District wise comparison reflect greatest proportion of kacha housing structures in District Malir (70%) and greatest proportion of kacha-pacca housing structures in District South (54%). Comparison of pacca housing structures shows half or more than half share in four districts namely Central (65%), West (54%), East (54%) and Korangi (50%). 3.3.4 Sources of Domestic Water Overall 67% slums have access to government water supply while a quarter of them use ground water for domestic use. City wise comparison reflects higher percentage of slums having access to government water sources. For example majority of the slums in Hyderabad (74%) compared to Karachi (65%) have access to government water supply. The slums in Hyderabad utilize only two sources of water i.e. ground water (26%) and government water supply (74%) while slums of Karachi utilize three sources of domestic water i.e. ground (23%), government (65%) and other sources (12%).

22%

9%

19%

30%

49%

34%

48%

43%

47%

Karachi

Hyderabad

Total

Figure 70: Housing Structures

Kacha Kacha-Pacca Pacca

31%

14%

6%

70%

3%

2%

9%

4%

32%

44%

3%

54%

44%

49%

65%

54%

50%

27%

43%

54%

43%

Central

East

Korangi

Malir

South

West

Hyderabad

Figure 69: Housing Structures

Kacha Kacha-Pacca Pacca

18%22%

17% 13% 12% 10%

44%

21%

3%4% 4%

14%

24%

22%

14%11% 10%

11%

Sindhi Urdu Pashto Punjabi Balochi Others

Figure 68: Commonly Spoken Language


26%19%

2%

6%

23%

7%

9%9%

14%

19%

0%

5%

11%

24%

18%

10%

23%

19%

0%

6%

21%

14%

2%

16%

14%

9%

0%

17%

12%

40%

4%

2%

25%

14%

0%

22%

16%

8%

6%

9%

32%

5%

0%

13% 22%

10%

4%

14%

21%4%

0%4% 3%

44%

10% 14%

Urdu Punjabi Potohari Balochi Pashto Sindhi Siraki Others

Figure 67: Commonnly Spoken Language


27

District wise comparison reflect that access of majority of the households in slums of four of the seven districts (Hyderabad, South, Malir, East) have relatively better access to government water supply where percentage ranges between 71% to 74%. Slums of two districts namely Central (31%) and Korangi (38%) utilize ground water besides government water source. Slums in all districts of Karachi utilize other sources of water with minor variations (4% to 12%) while this percentage is relatively higher in District West where about 29% slums utilize other sources of water beside government (47%) and ground water (24%). 3.3.5 Household Toilets 4% of the houses lack toilet facilities and are either using Neighbor’s/Public toilets or practicing open defecation. City wise comparison reflects that greater percentage of slums in Hyderabad (8%) is devoid of toilets compared to slums of Karachi (3%).

District wise comparison reflect households without toilet are highest in Hyderabad (8%) and District East (6%). The lowest percentage of households without toilets are found in three of the seven districts namely West (1%), South (2%) and Korangi (2%). The households where toilets are available have two types of toilets i.e. open pit toilets and toilets connected with street drain. Overall 13% households are found with open pit toilets. City wise comparison reflect Hyderabad has greater percentage of open pit toilets compared to Karachi (5%).

District wise comparison found none of the households of two districts namely South and Central having open pit toilet. A minimal percentage of households in three of the seven districts namely East (2%), Korangi (5%) and West (5%) have open pit toilets. Malir is the only district of the seven districts where 15% households have open pit toilets.

65%74%

51%

75% 71%

47%

74%

31% 19%

38%

13% 22%

24%

26%

4% 7% 11% 12% 7%

29%

0%

Figure 71: Sources of Water

Government Ground Water Other Sources

65%74%

67%

23%

26%

24%

12%0%

9%


Figure 72: Sources of Water

Government Ground Water Other Sources

0%

0%

2%

5%

5%

15%

43%

Central

South

East

Korangi

West

Malir

Hyderabad

Figure 75: Open Pit Toilet

3%

8%

4%


Figure 74: Unavailability of Toilet

5%

43%

13%


Figure 76: Open Pit Toilet

1%

2%

2%

4%

5%

6%

8%

West

South

Korangi

Central

Malir

East

Hyderabad

Figure 73: Unavailability of Toilet

28

Overall 82% households have toilets, which are connected with the street drain. City wise comparison reflect majority of the households of Karachi have toilets connected with street drain compared to Hyderabad where less than 50% toilets are connected with street drain. District wise comparison reflects that more than 90% households of five of the six districts have toilets connected with street drain. Malir is the only district where less than 80% slum households have toilets connected with street drain. 3.3.5 Major Professions Overall 54% families rely on daily wage labour for income while 35% families are job holders and 10% run small business to earn income. City wise comparison reflects that households of slums of Hyderabad (63%) have greater percentage of daily wage workers compared to slums of Karachi (52%). Households of slums of Karachi (39%) have slightly higher percentage of people holding jobs compared to Hyderabad (24%).

Daily wage work emerges as the profession of 54% to 63% slums of five of the seven districts. Percentage of job holders are greater in slums of two of the seven districts namely District Korangi (54%) and District Central. Slums have households engaged in small scale enterprise are less than 15% in slums of all seven districts. 3.4 Background Characteristics of Fully Immunized Vs. Zero Dose 3.4.1 Illiteracy in Mothers 93% mothers of zero dose children are illiterate or have only 1-5 years of schooling in comparison to 64% mothers of fully immunized children. The difference between educational levels of mothers of zero dose compared to fully immunized in slums of Karachi has greater variations compared to Hyderabad where difference of educational level of mothers of zero dose does not have significant variation with the mothers of fully immunized.

54%46%

37% 36% 35% 33%24%

9%13%

9% 9% 8% 8%13%

37% 41%54% 55% 57% 59% 63%

Figure 79: Major Professions

Jobs Small Enterprise Daily Wage Worker

49%

80%

92%

93%

94%

96%

98%

Hyderabad

Malir

East

Korangi

West

Central

South

Figure 77: Toilets Connected with Street Drain

39%

9%

52%

24%

13%

63%35%

10%

54%

Jobs Small Enterprise Daily Wage Worker

Figure 80: Major Professions


92%

49%

82%


Figure 78: Toilets Connected with Street Drain

29

District wise comparison reflects that 100% mothers of zero dose in District East are either illiterate or have 1-5 years of school education in contrast to 63% mothers of fully immunized children having either illiteracy or 1-5 years of schooling. The difference between educational levels of mothers of zero dose and fully immunized is very significant in four districts namely Central, Korangi, South and West where percentage of mothers of zero dose children is in 90s compared to mothers of fully immunized which is in 40s and 50s. 3.4.2 Housing Structures 29% houses of zero dose children are kacha26/tented, in contrast to only 5% kacha/tented houses of fully immunized children. A greater number of zero dose children of slums of Karachi (35%) have kacha/tented housing structures compared to zero dose children of slums of Hyderabad (20%). The percentage of kacha housing structures of fully immunized children is only 5% in both Karachi and Hyderabad.

The trend varies across districts. One district (Malir) has greater variation between housing structures of zero dose children and fully immunized, four districts (Hyderabad, Central, Korangi and East) have minor variations while two districts (West and South) have no variations at all. The variation between houses of zero dose and fully immunized children in District Malir is significant as 73% houses of zero dose are kacha/tented in comparison only 6% kacha houses of fully immunized children. 3.4.3 Unavailability of Household Toilets Overall 13% houses belonging to zero dose children are devoid of toilet facilities: whereas in contrast only 2% houses of fully immunized children do not have toilet facilities. The difference between unavailability of toilet in zero dose (17%) and fully immunized (5%) is greater in Hyderabad compared to Karachi.

26 Houses made of mud or straw or fabric

85%

89%

91%

94%

95%

97%

100%

49%

58%

76%

84%

53%

47%

63%

West

Korangi

Malir

Hyderabad

South

Central

East

Figure 81: Illiterate+School Years 1-5 in Mothers

Fully Immunzed Zero Dose

93% 94% 93%

58%

84%

64%


Figure 82: Illiterate+School Years 1-5 in Mothers

Zero Dose Fully Immunized

0%

0%

18%

18%

19%

20%

73%

4%

3%

12%

4%

3%

5%

6%

South

West

East

Korangi

Central

Hyderabad

Malir

Figure 83: Kacha Housing Structures

Fully Immunized Zero Dose

35%

20%

29%

5% 5% 5%


Figure 84: Kacha Housing Structures


30

Variations are observed across all districts and is more noticeable in District West. In District West where 26% houses of zero dose children are devoid of toilet facilities in comparison to 100% toilet availability in houses of fully immunized. The situation in District South is very interesting where 100% houses of zero dose children have toilets compared to houses of 1% fully immunized which are devoid of toilet facility. 3.4.4 Families Working as Daily Wage Workers Majority of the families belonging to zero dose children i.e. 61% rely on daily wage labor as source of income whereas the share is lower (50%) in the case of fully immunized children. City wise comparison found more variations in Karachi where families of 60% zero dose children are working as daily wage workers compared to only 47% fully immunized children while variation between families of zero dose (61%) and fully immunized children (59%) working as daily wage worker is minor in Hyderabad.

District wise comparison reflect greater variation in the professions of families of zero dose children and fully immunized in three districts namely District West, East and Korangi while this variation is opposite in District Malir where greater percentage of families of fully immunized children (52%) are working as daily wage worker compared to families of zero dose children (49%). 3.4.5 Debt Burden The debt burden in families of fully immunized children is relatively less than the families of zero dose children. 66% families of zero dose children face constant financial debt burden whereas this share is 57% in the case of fully immunized. City wise comparison reflects minor variation between debt burden of families of fully immunized and zero dose while this difference is great in families living in slums of Karachi where 76% families of zero dose are faced with the debt burden compared to 60% families of fully immunized in slums of Hyderabad.

0%

8%

11%

13%

14%

17%

26%

1%

4%

1%

1%

1%

5%

0%

South

Malir

Korangi

East

Central

Hyderabad

West

Figure 85: Unavailability of Household Toilet


11%

17%

13%

1% 5% 2%


Figure 86: Unavailability of Household Toilet


49%

57%

57%

61%

67%

74%

77%

52%

36%

50%

59%

34%

50%

54%

Malir

Central

South

Hyderabad

Korangi

East

West

Figure 87: Caregivers Working as Daily Wage Worker


60% 61% 61%47%

59%50%


Figure 88: Caregivers Working as Daily Wage Worker


31

District wise comparison indicate greater variation in economic condition of families of zero dose and fully immunized in District Korangi where 93% families of zero dose are faced with the debt burden compared to only 62% families of fully immunized. The lowest variation in economic condition of families of zero dose and fully immunized children is found in Hyderabad and District Malir.

48%

57%

73%

76%

78%

78%

93%

49%

44%

56%

71%

64%

68%

62%

Hyderabad

South

East

Malir

Central

West

Korangi

Figure 89: Financial Debt Burden

Fully Immunzed Zero Dose

76%

48%

66%60%

49%57%


Figure 90: Financial Debt Burden

Zero Dose Fully Immunzed

32

Chapter 4: Conclusion

The coverage survey was conducted with 5,990 children of 5,970 mothers living in 5,962 houses. The survey concludes that issue of partially vaccination is higher than the issue of zero dose. Although the percentage for partial vaccination and zero dose varies in each district but the variation is minor. Majority of the mothers have either no or low education (1-5 years of schooling) hence any awareness raising campaign can not be successful having reading materials. The retention of vaccination card is very low and educational levels in mothers are also very low hence accuracy of mothers recall is doubtful. Some of the major reasons of low retention of vaccination card are ‘loss, torn, thrown’ shows that majority of the mothers do not understand the importance of safe keeping of vaccination card. The percentage of retention of vaccination card and percentage of mothers having perception that vaccine protect children from diseases is almost same which means that majority of the mothers do not understand the importance of childhood vaccination. Another aspect of low retention of vaccination card is the literacy level of mothers. Majority of the mothers in slums of Hyderabad and Malir are either illiterate or have only 1-5 years of schooling have lowest percentage for retention of vaccination card. Similarly the literacy rate in District West and Central is better and retention of vaccination are highest compared to other districts. Some districts have higher percentage of zero dose and some districts have higher percentage of partially vaccinated. The sum of the two reflects roughly 45% children are either zero dose or partially vaccinated. Percentage of partially vaccinated and zero dose is also directly linked with the weak perception of mothers that vaccine protect children from diseases. Majority of the mothers in slums of Hyderabad and Malir do not know that vaccine prevent children from diseases hence percentage of zero dose or partially vaccinated are higher compared to other districts. The analysis of reasons of zero dose indicate non permission as one of the significant reasons. The data highlight that reasons of zero dose are also linked with the mothers weak perception that vaccine protect children from diseases. Majority of the mothers do not know that vaccine prevent children from disease hence most of the reasons are linked with the weak knowledge about importance of childhood vaccination. Non permission has emerged as the top most reasons of zero dose in five of the seven districts. It would be important to explore if the non permission is linked with the gender roles or it is linked with the low awareness levels in family decision makers only. Majority of the mothers of children who have had some vaccination or all vaccination of their children report that they get their child vaccinated from EPI facility. About 80% mothers or more with varied intensity across district report that EPI facility is not accessible. It would be important to explore definition of ‘access of EPI facility’ from mothers lens. The perception of mothers may provide more insights about tailoring strategies for increasing the coverage of zero dose and partially vaccinated. The areas with low access to EPI facilities may have intensified outreach. The outreach vaccination services can be made more successful with the support of LHWs. majority of the mothers are not aware of working of LHWs. those who are aware of working of LHWs think that they impart information about general health care. The awareness raising on importance of vaccination through LHWs is known by only 1% of the mothers which indicate under utilization of an important opportunity that works closely in the communities. The gender difference of fully immunized, zero dose and card retention indicates varied results. Percentage of fully immunized boys are higher compared to fully immunized girls. Similarly percentage of card retention for boys is higher than card retention for girls. Zero dose boys are higher than zero dose girls. It is important to explore gender aspect in future studies in more details to confirm if this variation is because of gender barriers or other barriers. The socio economic conditions of families of zero dose children are poorer than families of fully immunized children. This can be seen in four major variables i.e. literacy levels of mothers, daily wage work as a source of earning, kacha housing structures and unavailability of household toilet. The quality of life of families of zero dose children is poorer than the quality of life of families of fully immunized children. This calls for more equitable approach for strengthening routine immunization for everyone.

33

Chapter 5: Recommendations The recommendations are formulated according to the major findings and structured around the following headings: 5.1 Human Centric Design for Demand Generation Misinformation, fears and myths for catching more diseases are some of the predominant reasons of partial vaccination and zero dose. Although conventionally mosque announcements have been combined with the outreach camps but the mobilization of families requires a more human centric strategy for removing the misinformation, addressing the fears and myths. It is extremely important to combine mobilization sessions with the outreach camps to enhance its effectiveness. 5.2 Targeted Strategy for Covering Zero Dose and Partially Vaccinated 36% mothers indicated non-permission as some of the major reasons for the zero dose children. It is extremely important to enhance the horizon of awareness raising on importance of childhood immunization beyond mother. Targeted awareness raising campaign for family decision makers can be designed and launched for changing the mind set of family decision makers. 5.3 Channels of Communication Majority of the mothers (61%) prefer to receive information either through television or health worker (39%). This could be because of the low literacy levels in mothers as 56% mothers are illiterate and 16% mothers have education between 1-5 grades only. It is extremely important to use channels of communication preferred by mothers and other community members so that importance of childhood immunization could be understood and practices changed. 5.4 Team Work between LHWs & Vaccinators 5.4.1 49% mothers reported working of LHWs in their respective areas but only 5% mothers reported

engagement of LHWs for supporting childhood vaccination. This clearly reflects that the awareness raising of mothers on childhood immunization is an ignored topic. It is extremely important to prioritise list of topics for awareness raising for LHWs on a monthly basis. For example if evidence shows myths and biases against vaccination is one of the major reasons of mothers hesitating vaccination of their children then the LHWs can be guided for raising awareness on benefits of vaccination as a priority topic.

5.4.2 Since only 5% mothers reported that LHWs support vaccinators for outreach camps, this reflects poor coordination between LHWs and vaccinators. It is important to facilitate LHWs and vaccinators to prepare combined micro plans and its field implementation. Performance indicators and monthly accountability measures may help in improving the coverage rates in slums.

5.4.3 High performing LHWs and vaccinators may be awarded non-financial incentives such as certificate for best employee. Any LHW or vaccinator securing 12 certificates consecutively could be recommended for salary increments etc. This would improve the coordination and team work between LHWs and vaccinators.

5.5 Retention of Vaccination Card 5.5.1 Since vaccination card retention in slums is very challenging due to multiple reasons such as poor

housing and vulnerability due to thunder and rains, it is extremely important to design alternate mediums for punching the child vaccination there and then for families as well as at the vaccinators levels. This would help in enhancing the reliability of recall-based coverage (child registry and SMS reminders).

5.5.2 80% mothers reported that either the vaccination cards have been lost or torn or thrown. This clearly reflects the low levels of awareness about safe keeping of vaccination card. Multiple strategies could be introduced for highlighting the importance of safe keeping of vaccination card such as using CBVs and LHWs for undertaking personalized sessions and offering incentives to mothers such as certificate for the most responsible mother.

5.6 Other Alternatives 5.6.1 Childhood immunization based curriculum can be designed and offered with vocational skills

improvement programmes for mothers. This could be done through Civil Society Organisations or other UN programmes who work for unemployment. This would attract attention of mothers and their knowledge and comprehension on childhood immunization would be improved. The mothers would also be able to raise some livelihoods from the learnt vocational skills in the long run. This would address their one of the major economic challenge of regular financial debt.

34

5.6.2 Since 51% of slums are not covered by LHWs, local community volunteers can be identified and assigned responsibility of mobilizing children for childhood immunization. These local community volunteers could be offered incentives per child vaccinated especially during outreach camps. Availability of vaccination card could be utilized as a means of verification for determining the performance of community volunteers.

5.6.3 Some of the major reasons of zero dose and partially vaccinated children are poor socio economic background, constant struggle for raising livelihoods and meeting daily needs. Financial debts are some of the salient features of their lives. If EPI programme cannot improve their livelihoods, they can intensify the outreach camps to facilitate families not have additional expenses on the transportation for taking the child to the EPI centre.

5.6.4 The sanitary practices of families reflect that average user per toilet are 07. Majority of the children practice open defection in the streets and the overall environment is highly unhygienic. It is important to introduce some more measures for preventing diarrhoea such as construction of public toilets or introduction of community sanitation programme through Civil Society Organisations and or other development partners such as WASH programme of Unicef or UK Aid.

5.7 Accountability Design performance based intensive outreach camps and ensure accountability measures for compensating vaccinators according to the number of children vaccinated per c

35

Annex 1: Questionnaire for Household Coverage Survey Name of Enumerator

Date of interview

Select city name by circle the number from below, e.g., 2 for Hyderabad: 1. Karachi 2. Hyderabad

District name

Town/ tehsil name

Union Council name

Name of location

HHM1 Is this location a slum or underserved 1. Slum 2. Underserved

Coordinates

Name of household head

Household number. Please insert household numbers as 1, 2 , 3 etc. as you begin filling questionnaires from different households

Converted ID number (CID) Instructions for Supervisors: The logic of having Converted ID number (CID) is to ensure a unique ID for each HOUSEHOLD. The household number cannot be unique as different enumerators will collect data from different households on the same time and will enter household number of their own such as 1, 2, 3 etc. Once data collection by all enumerators is completed for the day, the supervisor or Team Leader) enter CID for each of the completed interviews on the MS EXCEL sheet. The supervisor should know the last CID entered. This will be continued in the following day. The supervisor will enter CIDs considering the last CID entered in the previous day.

HHMa Thanks! You will now be asked few questions on household socio economic information. How many members are currently living in your household?

HHMb How many of them are males? Please write your answer in numbers e.g. 2, 3, 4

HHMc How many females are in the household? Please write your answer in numbers e.g. 2, 3, 4

SE01 Since how long you (and your family members) are living here in this house/slum? Write the duration in number of years and months, e.g, 2 years and 3 months

SE02 If you have migrated from another place in the last 2 years, can you please pick a reason from the list below for coming/migrating to this slum? If you have been here for more than 2 years, please circle 6 1. To find a job/better life 2. Came from conflict affected area 3. We are displaced temporarily 4. We are nomads 5. Any other reason 6. Living here since for more than two

In case of nomads please specify the reason for moving and write this correct spellings and complete meaningful sentence

SE03 Which language is primarily used in your house with family members? Circle the correct number from below: If they choose 8: Please write which language is primarily spoken at home and not stated in the above mentioned list of languages 1. Urdu 2. Punjabi 3. Potohari 4. Balochi 5. Pashto 6. Sindhi 7. Siraiki 8. Other

SE04 What is type of infrastructure of main living room/bedroom of the house? If they choose 5: Please specify what is the other type of infrastructure of the main room of the house. 1. Kacha 2. Pacca 3. Mixed 4. Tented 5. Other type of infrastructure

SE05 How many (living rooms and bedrooms) are in the house? (Do not include kitchen, toilet, cattle-shed etc). Please write your answer in number only e.g. 1 or 2 or 3

SE06 How many members were in the house yesterday including any guests? Please write your answer in number only e.g. 1 or 2 or 3

SE07 Is electricity available/installed in your house? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

SE08 What is the main source of water for ALL PURPOSES in your house? If they select 7, please specify the water source in words other than stated above 1. Government water supply 2. Well 3. Hand pump 4. Buy from water tankers 5. Buy from the water man (Mashkee) 6. Tube wells 7. Other

36

SE09 What is the main source of DRINKING water? If the answer is other than specified the above please specify it in meaningful sentence 1. Government water supply 2. Well 3. Hand pump 4. Buy from water tankers 5. Buy from the water man (Mashkee) 6. Tube wells 7. Other

SE10 Do you have running water system installed in your house. The answer could be in 1 or 2 or in yes or no. If the answer is no then skip to question SE12 Yes No

SE11 If the running water system is installed in your house, then what is the duration of water availability?

SE12 Do you have functional or useable toilet available within your house? Please write your answer either in 1 or 2 or yes or no. If the answer is no then skip to question number SE15 Yes No

SE13 If you have toilet in your house, please specify its type of toilet/latrine, which is used by elder family members (not by children)? (Please check the availability of toilet if conveniently possible). Please write your answer in numbers by selecting from the stated list. If they select option 5, they will be taken to SE15. Connected with drain Flush to Sewage Traditional/Open pit Any other type of toilet

SE14 If you do have toilet in your house, how many people share one toilet in the house? Please write your answer in number only

SE15 If you do not have toilet in your house, where do you go for defection? If they choose 4: Please specify your answer in meaningful sentence 1. Neighbour's toilet 2. Public toilet 3. Open defecation 4. Other

SE16 What is the primary source of income of the household? Please write your answer in numbers by selecting from the stated list. If they choose 7: Please specify the primary source of income in complete meaningful sentence. 1. Government Job 2. Private job (factory worker, etc.) 3. Work in foreign country 4. Small business (shop keeper, etc.) 5. Work as daily wage labors 6. Taxi driver 7. Other

SE17 Tell us the economic/income situation of your household (Reference period is last one year) Please write your answer in numbers by selecting from the stated list. 1. Debt 2. Breakeven (No Debt, No Savings) 3. Savings

Enter Converted ID number (CID)

Please write mother number, e.g., write "1" if its the first mother of the house you are interviewing

Please write mother's mobile number if mother does not have a mobile number, please record mobile number of any other family member who lives in the same house

SD01 How old are you? Please write your answer in number of years e.g. 20, 25, 30 etc.

SD02 How many years of schooling did you finish? Please write your answer in numbers e.g. 0,1, 2, 3, 4 etc.

SD03 Are you employed outside home? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

SD04 How many children between 12 to 23 months? Please write your answer in number e.g. 1, 2, 3, 4 etc.

KP01a Have you ever received information about childhood vaccination or immunization through TV? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP02b Have you ever received information about childhood vaccination or immunization through radio? 1. Yes 2. No

KP03a Have you ever received information about childhood vaccination or immunization through a poster or a bill board? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP03b Have you ever received information about childhood vaccination or immunization through a leaflet? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP03c Have you ever received information about childhood vaccination or immunization through health workers/LHVs? Please write your answer either in 1 or 2 or yes or no

37

KP03d Have you ever received information about childhood vaccination from sources other than specified above? Please write your answer either in 1 or 2 or yes or no. If yes, please specify it. 1. Yes 2. No

KP04a Do you know if there is any fixed EPI facility in your slum or under served area?

KP04b Have you gotten your children immunised? Please write your answer either in 1 or 2 or yes or no. If the answer to this question is no then skip to question K06 1. Yes 2. No

KP05a Did you ever get immunisation services for your child or got your child immunised from a fixed public EPI facility? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP05b Did you ever get immunisation services for your child or got your child immunised from an outreach vaccination camp? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP05c Did you ever get immunisation services for your child or got your child immunised through a Lady Health Worker? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP05d Did you ever get immunisation services for your child or got your child immunised through a doctor in private health facility? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP05e Did you ever get immunisation services for your child or got your child immunised from EPI facility other than specified above? Please write your answer either in 1 or 2 or yes or no. If the answer is yes, then specify the type of facility from where the child got immunisation services in a correct spelling and complete meaningful sentence. 1. Yes 2. No

KP06 If you do not get your child immunised, please share reason for not getting your child immunised? If the answer is other than the listed in points 1-10, please specify. 1. Was not aware of EPI/outreach center 2. Did not know the timing/hours 3. Did not have time to go 4. No enabling environment in EPI center 5. Transport cost/opportunity cost 6. Family/husband did not allow 7. Fear of injection 8. It causes more diseases 9. Wastage of time 10. Other

KP07 Have you ever heard of Lady Health Workers (LHWs) working in your area? Please write your answer either in 1 or 2 or yes or no If they select option 2, then skip KP08 1. Yes 2. No

KP08 Please tell us what they (LHWs) do? (As the interviewer, do not read the following options to the respondent. 1. Promote health education 2. Supply FP methods 3. Treat illness 4. Refer to hospital 5. Vaccinate/help vaccinator 6. Don't know

Write Converted ID number

Please write mother number, e.g., if you are interviewing the 2nd mother of the same house, write "2"

Please write mother's mobile number if the mother does not have mobile number please get the number of any other family member who lives in the same house

For every child under the age of 2, ask his/her mother the following questions

CH01 What is the sex of child? 1. Male 2. Female

CH02 What is the age of child in months? If the age of the child is in days, please specify number with a word e.g. 01 year, 009 months or 15 days

CH03 Has the child ever been given vaccine? Please write your answer either in 1 or 2 or yes or no. If the answer to this question is no then skip to question CH12 1. Yes 2. No

CH04 If the child was given any vaccine, please ask the mother to show the vaccination card? If the card is available then answer yes or 1 (If card is available, then use it to record immunization status of the child below. Ask the following question if the child has not received all expected doses). If card is not available then record the status of vaccination on re-call basis. 1. Yes 2. No

CH04a What is the reason for not showing the vaccination card 1. Card has not been issued

38

2. Card has lost 3. Card is torn 4. Others

CH05 Has the child ever been given BCG vaccination immediately after the birth? You may ask first dose of the vaccine. Please write your answer either in 1 or 2 or yes or no Interviewer: Confirm if BCG is given by asking how was given, any scar mark on the arm of the child. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH06 Has the child been given BCG to protect him/her immediately after the birth or later? 1. Date 2. No

Has the child been given OPV to protect him/her immediately after the birth or later? 1. Date 2. No

Has the child' been given vaccination at the age of 06 weeks or later? Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis

OPV-1 Date: No:

CH07 Rota 1 Date: No:

Penta 1 Date: No:

PCV10-1/ Pneumo-1 Date: No:

CH08 Has the child' been given vaccination at the age of 10 weeks or later? Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis

OPV-2 Date: No:

ROTA-2 Date: No:

PENTA-2 Date: No:

PCV10-2/Pneumo-2 Date: No:

CH09 Has the child' been given vaccination at the age of 14 weeks or later? Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis

OPV-3 Date: No:

IPV Date: No:

PENTA-3 Date: No:

PCV10-3/Pneumo-3 Date: No:

CH10 Has the child' been given Measles 1 at the age of 09 months or later? Please write your answer either in 1 or 2 or yes or no. Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis. 1. Yes Date:______________ 2. No

CH11 Has the child' been given Measles 2 at the age of 15 months or later? Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes Date:______________ 2. No

CH11A What are the reasons for not continuing vaccination? More than one answer can be circled upon.

1. They have no EPI related information

2. They do not know the timings

3. They have no time to visit the center

4. The environment of Vaccination Centers in not good

5. Transport cost

6. Family members/Husband does not allow

7. Fear of Injection

8. Wastage of time

9. It causes more diseases

10. Others

If there is a reason apart from the reasons cited above, please mention this here.

CH12 Does this mother have another child who is 12-23 months of age? Please write your answer either in 1 or 2 or yes or no. If they select option 1, they will get the message: "Let’s start interviewing her" and Part B of the questionnaire will start running again. If they select option 2, they will receive the message: "Thanks. Your responses have been recorded and the interview has ended. 1. Yes 2. No

39

Annex 2: Analysis of Household Coverage Survey Status of Children

Table 1: Gender Wise Total Children

Districts Boys Girls Total

Central 352 53% 316 47% 668 100%

East 440 52% 407 48% 847 100%

Korangi 297 52% 271 48% 568 100%

Malir 435 51% 410 49% 845 100%

South 454 54% 394 46% 848 100%

West 431 51% 418 49% 849 100%

Sub Total 2409 52% 2216 48% 4625 100%

Hyderabad 732 54% 633 46% 1365 100%

Grand Total 3141 52% 2849 48% 5990 100%

Table 2: Total Children With and Without Vaccination Card and Zero Dose

Districts Zero Dose With Vaccination Card (Record) Without Vaccination Card (Recall) Total

# % # % # % # %

Central 37 6% 359 54% 272 40% 668 100%

East 45 5% 370 44% 432 51% 847 100%

Korangi 27 5% 246 43% 295 52% 568 100%

Malir 91 11% 254 30% 500 59% 845 100%

South 21 2% 364 43% 463 55% 848 100%

West 27 3% 531 63% 291 34% 849 100%

Sub Total 248 5% 2124 46% 2253 49% 4625 100%

Hyderabad 143 10% 355 26% 867 64% 1365 100%

Grand Total 391 7% 2479 41% 3120 52% 5990 100%

Table 3: Total Children with and without Vaccination Card

Districts

With Card (Record) Without Card (Recall) Total Children

Male Female Total Male Female Total

# % # % # % # % #

Central 179 50% 180 50% 359 154 57% 118 43% 272 668

East 205 55% 165 45% 370 214 50% 218 50% 432 847

Korangi 129 52% 117 48% 246 154 52% 141 48% 295 568

Malir 135 53% 119 47% 254 249 50% 251 50% 500 845

South 186 51% 178 49% 364 253 55% 210 45% 463 848

West 280 53% 251 47% 531 135 46% 156 54% 291 849

Sub Total 1114 52% 1010 48% 2124 1159 51% 1094 49% 2253 4625

Hyderabad 192 54% 163 46% 355 466 54% 401 46% 867 1365

Grand Total 1306 53% 1173 47% 2479 1625 52% 1495 48% 3120 5990

Table 4: Reasons of not having vaccination Card

Districts

Never Given Card is Lost/Torn/Thrown Card is not available at the moment Total

# % # % # %

Central 6 2% 186 79% 80 29% 272

East 53 12% 344 80% 35 8% 432

Korangi 5 2% 267 90% 23 8% 295

Malir 11 5% 364 70% 125 25% 500

South 40 9% 400 83% 23 8% 463

West 2 1% 257 88% 32 11% 291

Total 117 5% 1818 81% 318 14% 2253

Denominator is 2253 (total number of children in 6 districts who do not have cards)- this question was not asked in Hyderabad

Table 5: Status of Zero Dose Children

Districts

Zero Dose

Male Female Total

# % # %

Central 19 51% 18 49% 37

East 21 47% 24 53% 45

Korangi 14 52% 13 48% 27

Malir 51 56% 40 44% 91

South 15 71% 6 29% 21

West 16 59% 11 41% 27

Sub Total 136 55% 112 45% 248

Hyderabad 74 52% 69 48% 143

Grand Total 210 54% 181 46% 391

Denominator is 391 (total number of zero dose children out of total children)

40

Table 6: Antigen Wise Coverage of Total Children Age 12-23 Months (Record + Recall)

Districts Central East Korangi Malir South West Total Hyderabad Grand Total

Total Eligible Children # 668 847 568 845 848 849 4625 1365 5990

BCG # 624 774 538 746 820 810 4312 1211 5523

93% 91% 95% 88% 97% 95% 93% 89% 92%

Penta 1 # 570 728 483 636 730 710 3857 1129 4986

85% 86% 85% 75% 86% 84% 83% 83% 83%

Penta 2 # 526 638 421 538 671 640 3434 1084 4518

79% 75% 74% 64% 79% 75% 74% 79% 75%

Penta 3 # 478 550 377 489 621 583 3098 1009 4107

72% 65% 66% 58% 73% 69% 67% 74% 69%

Measles 1 # 361 493 342 466 526 519 2707 869 3576

54% 58% 60% 55% 62% 61% 59% 64% 60%

OPV 0 # 608 748 527 739 810 794 4226 1201 5427

% 91% 88% 93% 87% 96% 94% 91% 88% 91%

OPV 1 # 543 711 477 606 724 650 3711 1066 4777

% 81% 84% 84% 72% 85% 77% 80% 78% 80%

OPV 2 # 495 624 414 505 655 575 3268 1004 4272

% 74% 74% 73% 60% 77% 68% 71% 74% 71%

OPV 3 # 468 542 379 486 614 555 3044 982 4026

% 70% 64% 67% 58% 72% 65% 66% 72% 67%

Pneumococcal 1 # 550 694 477 626 719 701 3767 1083 4850

% 82% 82% 84% 74% 85% 83% 81% 79% 81%

Pneumococcal 2 # 507 611 415 529 658 631 3351 973 4324

% 76% 72% 73% 63% 78% 74% 72% 71% 72%

Pneumococcal 3 # 453 525 370 481 606 561 2996 959 3955

% 68% 62% 65% 57% 71% 66% 65% 70% 66%

Rota 1 # 341 351 342 491 468 306 2299 801 3100

% 51% 41% 60% 58% 55% 36% 50% 59% 52%

Rota 2 # 316 323 306 423 436 292 2096 708 2804

% 47% 38% 54% 50% 51% 34% 45% 52% 47%

IPV # 435 448 374 481 604 557 2899 905 3804

% 65% 53% 66% 57% 71% 66% 63% 66% 64%

Table 7: Gender Wise Antigen Coverage of Total Children Age 12-23 Months (Record + Recall)

Districts

Penta1 OPV1 Pneumococcal 1

Penta2 OPV 2 Pneumococcal 2

Penta3 OPV 3 Pneumococcal 3 Measles 1

% % % % % % % % % %

Central

Male 54% 54% 54% 56% 56% 56% 57% 57% 57% 56%

Female 46% 46% 46% 44% 44% 44% 43% 43% 43% 44%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

East

Male 53% 53% 53% 55% 55% 55% 55% 56% 55% 55%

Female 47% 47% 47% 45% 45% 45% 45% 44% 45% 45%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

West

Male 52% 53% 53% 52% 52% 52% 53% 53% 53% 53%

Female 48% 47% 47% 48% 48% 48% 47% 47% 47% 47%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

West

Male 50% 50% 50% 49% 49% 49% 51% 51% 51% 51%

Female 50% 50% 50% 51% 51% 51% 49% 49% 49% 49%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

South

Male 54% 53% 54% 54% 53% 54% 53% 53% 53% 53%

Female 46% 47% 46% 46% 47% 46% 47% 47% 47% 47%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

West

Male 51% 50% 50% 50% 50% 50% 51% 51% 51% 51%

Female 49% 50% 50% 50% 50% 50% 49% 49% 49% 49%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Sub Total

Male 52% 52% 52% 53% 53% 53% 53% 53% 53% 53%

Female 48% 48% 48% 47% 47% 47% 47% 47% 47% 47%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Hyderabad

Male 54% 54% 54% 53% 53% 54% 53% 53% 53% 54%

Female 46% 46% 46% 47% 47% 46% 47% 47% 47% 46%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Grand Total

Male 53% 53% 53% 53% 53% 53% 53% 53% 53% 53%

Female 47% 47% 47% 47% 47% 47% 47% 47% 47% 47%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

41

Table 8: Percentage of Antigen Wise Coverage of Total Children Age 12-23 Months (Record Basis)

Districts Central East Korangi Malir South West Total Hyderabad Grand Total

Total Eligible Children # 668 847 568 845 848 849 4625 1365 5990

BCG % 53% 42% 43% 29% 43% 61% 45% 26% 41%

OPV0 % 51% 42% 41% 29% 42% 60% 44% 26% 40%

Penta 1 % 50% 41% 41% 26% 41% 59% 43% 25% 39%

OPV1 % 45% 40% 40% 22% 40% 52% 40% 22% 36%

Pneumococcal 1 % 47% 39% 40% 25% 40% 57% 41% 23% 37%

Penta 2 % 47% 38% 38% 23% 39% 54% 40% 24% 36%

OPV2 % 42% 37% 38% 18% 37% 46% 36% 21% 33%

Pneumococcal 2 % 45% 37% 38% 22% 38% 53% 39% 23% 35%

Penta 3 % 42% 34% 34% 20% 35% 49% 36% 22% 33%

OPV3 % 40% 33% 34% 20% 34% 46% 35% 21% 32%

Pneumococcal 3 % 40% 32% 33% 20% 34% 47% 34% 21% 31%

Measles 1 % 36% 30% 32% 19% 32% 47% 33% 19% 29%

IPV % 40% 28% 34% 19% 34% 47% 34% 18% 30%

Table 9: Number of Antigen Wise Coverage of Total Children Age 12-23 Months (Record Basis)

Central East Korangi Malir South West Total Hyderabad Grand Total

BCG # 356 359 243 248 361 522 2089 354 2443

OPV0 # 342 359 235 242 356 511 2045 353 2398

Penta 1 # 331 351 234 220 351 497 1984 337 2321

OPV1 # 300 341 229 186 338 440 1834 299 2133

Pneumococcal 1 # 317 333 229 211 341 488 1919 317 2236

Penta 2 # 315 323 218 192 334 458 1840 326 2166

OPV2 # 278 313 213 156 316 391 1667 283 1950

Pneumococcal 2 # 301 310 213 184 322 451 1781 311 2092

Penta 3 # 282 289 194 172 300 419 1656 305 1961

OPV3 # 269 283 196 169 289 393 1599 288 1887

Pneumococcal 3 # 264 275 187 165 288 397 1576 287 1863

Measles 1 # 239 253 181 159 274 398 1504 260 1764

IPV # 267 240 191 164 292 397 1551 246 1797

Denominator is 2479 (total number of children who have vaccination card)

Table 10: Gender Wise Antigen Coverage of Total Children Age 12-23 Months (Record )

Districts Gender Penta 1 OPV 1

Pneumo- coccal 1

Penta 2 OPV 2 Pneumococcal 2 Penta 3 OPV 3 Pneumococcal 3 Measles 1

% % % % % % % % % %

Central

Male 51% 51% 51% 52% 52% 52% 53% 53% 53% 54%

Female 49% 49% 49% 48% 48% 48% 47% 47% 47% 46%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

East

Male 57% 56% 57% 58% 58% 58% 60% 60% 60% 60%

Female 43% 44% 43% 42% 42% 42% 40% 40% 40% 40%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

West

Male 52% 53% 52% 52% 53% 53% 51% 52% 51% 50%

Female 48% 47% 48% 48% 47% 47% 49% 48% 49% 50%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

West

Male 52% 53% 52% 51% 53% 51% 53% 53% 52% 53%

Female 48% 47% 48% 49% 47% 49% 47% 47% 48% 47%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

South

Male 50% 50% 50% 51% 51% 50% 49% 49% 47% 50%

Female 50% 50% 50% 49% 49% 50% 51% 51% 43% 50%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

West

Male 53% 51% 52% 53% 52% 53% 54% 54% 54% 53%

Female 47% 49% 48% 47% 48% 47% 46% 46% 46% 47%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Total

Male 53% 52% 52% 53% 53% 53% 54% 54% 53% 53%

Female 47% 48% 48% 47% 47% 47% 46% 46% 47% 47%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Hyderabad

Male 54% 54% 55% 54% 53% 54% 55% 55% 56% 54%

Female 46% 46% 45% 46% 47% 46% 45% 45% 44% 46%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Grand Total

Male 53% 52% 53% 53% 53% 53% 54% 54% 53% 54%

Female 47% 48% 47% 47% 47% 47% 46% 46% 47% 46%

Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Denominator is 2479 (total number of children who have vaccination card)

42

Table 11: Fully Immunized Children on the Basis of Record + Recall

Districts Total Children # of Fully Immunized Children

# # %

Central 668 334 50%

East 847 447 53%

Korangi 568 322 57%

Malir 845 424 50%

South 848 499 59%

West 849 475 56%

Sub Total 4625 2501 54%

Hyderabad 1365 811 59%

Grand Total 5990 3312 55%

Table 12: Fully Immunized Children on the Basis of Record

Districts Total Children # of Fully Immunized Children

# # %

Central 668 214 32%

East 847 230 27%

Korangi 568 169 30%

Malir 845 131 16%

South 848 259 31%

West 849 358 42%

Sub Total 4625 1361 29%



Table 13: Gender of Fully Immunized Children on Record Basis

Districts Male Female Total

# % # %

Central 118 55% 96 45% 214

East 140 61% 90 39% 230

Korangi 84 50% 85 50% 169

Malir 70 53% 61 47% 131

South 131 51% 128 49% 259

West 191 53% 167 47% 358

Sub Total 734 54% 627 46% 1361

Hyderabad 132 54% 112 46% 244

Grand Total 866 54% 739 46% 1605

Table 14: Gender of Fully Immunized Children on Record + Recall Basis


# % # %

Central 190 57% 144 43% 334

East 247 55% 200 45% 447

Korangi 169 52% 153 48% 322

Malir 213 50% 211 50% 424

South 270 54% 229 46% 499

West 242 51% 233 49% 475

Sub Total 1331 53% 1170 47% 2501

Hyderabad 432 53% 379 47% 811

Grand Total 1763 53% 1549 47% 3312

Table 15a: Partially Vaccinated Children (Record + Recall)

Districts FI (Record + Recall) ZD Partially Vaccinated

Central 334 37 297 44%

East 447 45 355 42%

Korangi 322 27 219 39%

Malir 424 91 330 39%

South 499 21 328 39%

West 475 27 347 41%

Sub Total 2501 248 1876 41%

Hyderabad 811 143 411 30%

Grand Total 3312 391 2287 38%

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Table 15b: Gender wise Partially Immunized Children on Record + Recall Basis


# % # %

Karachi-Central 143 48% 154 52% 297

Karachi -East 172 48% 183 52% 355

Karachi -Korangi 113 52% 106 48% 219

Karachi -Malir 171 52% 159 48% 330

Karachi -South 169 52% 159 48% 328

Karachi -West 173 50% 174 50% 347

Sub Total 941 50% 935 50% 1876

Hyderabad 226 55% 185 45% 411

Grand Total 1167 51% 1120 49% 2287

Table 16a: Partially Vaccinated Children (Record)

Districts FI (Record) With Card Partially Vaccinated

Central 214 359 145 22%

East 230 370 140 17%

Korangi 169 246 77 14%

Malir 131 254 123 15%

South 259 364 105 12%

West 358 531 173 20%

Sub Total 1361 2124 763 16%

Hyderabad 244 355 111 8%

Grand Total 1605 2479 874 15%

Table 16b: Gender wise Partially Immunized Children on Record Basis

Districts # % # % Total

Central 61 42% 84 58% 145

East 65 46% 75 54% 140

Korangi 44 57% 33 43% 77

Malir 65 53% 58 47% 123

South 55 52% 50 48% 105

West 89 51% 84 49% 173

Sub Total 379 50% 384 50% 763

Hyderabad 59 53% 52 47% 111

Grand Total 438 50% 436 50% 874

Correlation of Zero Dose and Fully Immunized Children with Socio Economic Conditions

Table 17: Status of Zero Dose Children

Districts Zero dose Children

Central 37

East 45

Korangi 27

Malir 91

South 21

West 27

Sub Total 248

Hyderabad 143

Grand Total 391

Denominator is 391 (total number of zero dose children)

Table 18: Infrastructure of Houses of Zero Dose

Districts Kacha Kacha-Pacca Pacca Total

# % # % # % # %

Central 7 19% 17 46% 13 35% 37 100%

East 8 18% 14 31% 23 51% 45 100%

Korangi 5 18% 14 52% 8 30% 27 100%

Malir 66 73% 3 3% 22 24% 91 100%

South 0 0% 19 90% 2 10% 21 100%

West 0 0% 22 81% 5 19% 27 100%

Sub Total 86 35% 89 36% 73 29% 248 100%

Hyderabad 29 20% 70 49% 44 31% 143 100%

Grand Total 115 29% 159 41% 117 30% 391 100%

44

Table 19: Family Sizes of Zero Dose

Districts Average Family Size Male Members Female Members Total Members

# % # % # %

Central 7 142 54% 122 46% 264 100%

East 8 186 51% 180 49% 366 100%

Korangi 5 71 50% 70 50% 141 100%

Malir 7 318 50% 318 50% 636 100%

South 8 82 50% 83 50% 165 100%

West 6 76 47% 85 53% 161 100%

Sub Total 7 875 50% 858 50% 1733 100%

Hyderabad 7 529 51% 511 49% 1040 100%

Grand Total 8 1404 51% 1369 49% 2773 100%

Table 20: Availability of Types of Toilet in the Houses of Zero Dose Children

Districts Connected with Street Drain Traditional/open pit Houses without Toilets Total

# % # % # % # %

Central 32 86% 0 0% 5 14% 37 100%

East 39 87% 0 0% 6 13% 45 100%

Korangi 21 88% 3 12% 3 11% 27 100%

Malir 68 75% 16 17% 7 8% 91 100%

South 21 100% 0 0% 0 0% 21 100%

West 19 70% 1 4% 7 26% 27 100%

Sub Total 200 81% 20 8% 28 11% 248 100%

Hyderabad 54 38% 65 45% 24 17% 143 100%

Grand Total 254 65% 85 22% 52 13% 391 100%

Table 21: Mode of Defecation in the absence of Toilets

Districts Neighbor’s Toilets Public toilet Open Defecation Total

# % # % # % # %

Central 0 0% 0 0% 5 14% 5 14%

East 2 4% 0 0% 4 9% 6 13%

Korangi 0 0% 3 11% 0 0% 3 11%

Malir 1 1% 6 7% 0 0% 7 8%

South 0 0% 0 0% 0 0% 0 0%

West 0 0% 7 26% 0 0% 7 26%

Sub Total 3 1% 16 6% 9 4% 28 11%

Hyderabad 8 6% 8 6% 8 6% 24 17%

Grand Total 11 21% 24 46% 17 33% 52 13%

Denominator is 52 (houses without toilet facility are 52 out of 391 )

Table 22: Sources of Livelihoods of Zero Dose Children

Districts Job Holders Small Business Daily wage Worker Other Total

# % # % # % # % # %

Central 10 27% 6 16% 21 57% 0 0% 37 100%

East 10 22% 2 4% 33 74% 0 0% 45 100%

Korangi 7 26% 2 7% 18 67% 0 0% 27 100%

Malir 27 30% 19 21% 45 49% 0 0% 91 100%

South 6 29% 3 14% 12 57% 0 0% 21 100%

West 5 19% 1 4% 21 77% 0 0% 27 100%

Sub Total 65 26% 33 13% 150 60% 0 0% 248 100%

Hyderabad 21 15% 22 15% 87 61% 13 9% 143 100%

Grand Total 86 22% 55 14% 237 61% 13 3% 391 100%

Table 23: Status of Income and Expenditures in Households of Zero Dose Children

Districts Debt Breakeven (No Debt, No Savings) Savings Total

# % # % # % # %

Central 29 78% 7 19% 1 3% 37 100%

East 33 73% 12 27% 0 0% 45 100%

Korangi 25 93% 2 7% 0 0% 27 100%

Malir 69 76% 19 21% 3 3% 91 100%

South 12 57% 9 43% 0 0% 21 100%

West 21 78% 6 22% 0 0% 27 100%

Sub Total 189 76% 55 22% 4 2% 248 100%

Hyderabad 68 48% 70 49% 5 3% 143 100%

Grand Total 257 66% 125 32% 9 2% 391 100%

45

Table 24: Education Level of Mothers of Zero Dose Children

# of School Years

Central East Korangi Malir South West Total Hyderabad Grand Total

# % # % # % # % # % # % # % # % # %

0 (Illiterate) 28 76% 44 98% 21 78% 76 83% 17 81% 20 74% 206 83% 116 81% 322 82%

01--05 8 21% 1 2% 3 11% 7 8% 3 14% 3 11% 25 10% 18 13% 43 11%

06--10 1 3% 0 0% 3 11% 6 7% 1 5% 3 11% 14 6% 5 3% 19 5%

11--15 0 0% 0 0% 0 0% 2 2% 0 0% 1 4% 3 1% 4 3% 7 2%

Total 37 100% 45 100% 27 100% 91 100% 21 100% 27 100% 248 100% 143 100% 391 100%

Table 25: Reasons for Zero Dose Children

Reasons

Central East Korangi Malir South West Sub Total Hyderabad Grand Total # % # % # % # % # % # % # % # % # %

Unavailability of Time for Vaccination

1 3% 5 11% 1 4% 22 24% 1 5% 2 7% 32 13% 36 25% 68 17%

Family/husband did not allow

17 46% 19 42% 19 70% 41 45% 6 29% 17 63% 119 48% 23 16% 142 36%

Causes Diseases 8 22% 10 22% 11 41% 42 46% 5 24% 10 37% 56 35% 76 53% 162 41%

Went to Punjab 1 3% 0 0% 0 0% 0 0% 0 0% 0 0% 1 0% 0 0% 1 0%

Unaware of importance of EPI

6 16% 1 2% 0 0% 0 0% 0 0% 0 0% 7 3% 0 0% 7 2%

Wastage of time 1 3% 1 2% 2 7% 0 0% 1 5% 0 0% 5 2% 6 3% 11 3%

No enabling environment in EPI

1 3% 0 0% 0 0% 3 3% 0 0% 0 0% 4 2% 0 0% 4 1%

Fear of Injection 6 16% 5 11% 8 30% 15 16% 5 24% 2 7% 41 17% 20 14% 61 16%

Was not aware of EPI/ outreach Center

8 22% 7 16% 2 7% 4 4% 1 5% 4 15% 26 10% 2 1% 28 7%

Child was sick 1 3% 4 9% 0 0% 3 3% 2 10% 2 7% 12 5% 0 0% 12 3%

Did not know the timing

4 11% 5 11% 2 7% 1 1% 0 0% 1 4% 13 5% 2 1% 15 4%

No Facility Available

0 0% 0 0% 0 0% 1 1% 0 0% 0 0% 1 0% 0 0% 1 0%

Transport Cost/ Opportunity Cost

0 0 0 0% 2 7% 3 3% 0 0% 1 4% 6 2% 3 2% 9 2%

Total 54 146% 57 127% 47 174% 135 145% 21 100% 39 144% 353 142% 168 115% 521 133%

Denominator is 391 (total number of zero dose children)- Multiple Responses

Table 26: Reasons of not Continuing Vaccination (Multiple Answers)

Reasons Central East Korangi Malir South West Grand Total

# % # % # % # % # % # % # %

Did not have time to go 0 0% 0 0% 14 6% 3 1% 107 33% 0 0% 124 7%

Family/husband did not allow

24 8% 22 6% 54 25% 50 15% 44 13% 36 10% 230 12%

It causes more diseases 47 16% 35 10% 22 10% 22 7% 18 5% 36 10% 180 10%

Relocated 0 0% 0 0% 0 0% 4 1% 0 0% 0 0% 4 0%

Unaware of Vaccination 149 50% 207 58% 11 5% 3 1% 9 3% 151 44% 530 28%

Wastage of time 0 0% 0 0% 2 1% 31 9% 4 1% 0 0% 37 2%

No enabling environment in EPI

0 0% 0 0% 0 0% 0 0% 1 0% 0 0% 1 0%

Fear of Injection 47 16% 25 7% 24 11% 25 8% 18 5% 8 2% 147 8%

Was not aware of EPI/ outreach Center

0 0% 0 0% 4 2% 7 2% 0 0% 0 0% 11 1%

Child was sick 30 10% 66 19% 28 13% 44 13% 116 35% 116 34% 400 21%

Card was lost 0 0% 0 0% 8 4% 10 3% 5 2% 0 0% 23 1%

Did not know the timing 0 0% 0 0% 39 18% 101 31% 3 1% 0 0% 143 8%

No Facility Available 0 0% 0 0% 1 0% 21 6% 0 0% 0 0 22 1%

Transport Cost/ Opportunity Cost

0 0% 0 0% 12 5% 9 3% 3 1% 0 0% 24 1%

This question was only asked in 6 districts of Karachi. 1876 children discontinued the vaccination and given multiple reasons for this.

46

Fully Immunized Table 27: Status of Fully Immunized Children

Districts Total Children # of Fully Immunized Children % of Fully Immunized Children

Central 668 334 50%

East 847 447 53%

Korangi 568 322 57%

Malir 845 424 50%

South 848 499 59%

West 849 475 56%

Sub Total 4625 2501 54%



Table 28: Infrastructure of Houses of Fully immunized Children


# % # % # % # %

Central 11 3% 82 25% 239 72% 332 100%

East 54 12% 138 31% 253 57% 445 100%

Korangi 12 4% 135 42% 175 54% 322 100%

Malir 26 6% 280 66% 117 28% 423 100%

South 22 4% 249 50% 224 45% 495 100%

West 12 3% 175 37% 288 61% 475 100%

Sub Total 137 5% 1059 42% 1296 52% 2492 100%

Hyderabad 41 5% 381 47% 389 48% 811 100%

Grand Total 178 5% 1440 44% 1685 51% 3303 100%

Denominator is 3303 (infrastructure of houses of 3312 fully immunized children)

Table 29: Family Sizes of Fully Immunized Children

Districts Average Family Size Male Members Female Members Total Members

# % # % # %

Central 7 1135 51% 1075 49% 2210 100%

East 6 1387 50% 1365 50% 2753 100%

Korangi 6 1025 51% 968 49% 1993 100%

Malir 7 1395 50% 1379 50% 2774 100%

South 6 1613 51% 1557 49% 3170 100%

West 6 1515 50% 1514 50% 3029 100%

Sub Total 6 8070 51% 7858 49% 15928 100%

Hyderabad 8 3205 50% 3192 50% 6397 100%

Grand Total 7 11275 51% 11050 49% 22325 100%

Table 30: Availability of Types of Toilet in the Houses of Fully Immunized Children

Districts Connected With Drains Traditional/open pit Houses without Toilets Total

# % # % # % # %

Central 330 99% 0 0% 2 1% 332 100%

East 433 97% 8 2% 4 1% 445 100%

Korangi 314 98% 5 2% 3 1% 322 100%

Malir 354 84% 53 13% 16 4% 423 100%

South 487 98% 1 0% 7 1% 495 100%

West 466 98% 9 2% 0 0% 475 100%

Sub Total 2384 96% 76 3% 32 1% 2492 100%

Hyderabad 433 53% 340 42% 38 5% 811 100%

Grand Total 2817 85% 416 13% 70 2% 3303 100%

Table 31: Mode of Defecation in the Absence of Toilets

Districts Neighbor’s Toilets Public toilet Open Defecation Total

# % # % # % # %

Central 1 50% 0 0% 1 0% 2 0

East 0 0% 0 0% 4 1% 4 1%

Korangi 0 0% 3 1% 0 0% 3 1%

Malir 0 0% 15 94% 1 6% 16 100%

South 0 0% 1 14% 6 86% 7 100%

West 0 0% 0 0% 0 0% 0 0%

Sub Total 1 3% 19 59% 12 38% 32 100%

Hyderabad 5 14% 0 0% 32 86% 37 100%

Grand Total 6 9% 19 28% 44 64% 69 100%

Denominator is 69 (houses without toilet facility of fully immunized children= total houses are 3303 of fully immunized children)

47

Table 32: Sources of Livelihoods

Districts Job Holders Small Business Daily wage Worker Total

# % # % # % # %

Central 174 52% 39 12% 119 36% 332 100%

East 183 41% 40 9% 222 50% 445 100%

Korangi 191 59% 22 7% 109 34% 322 100%

Malir 177 42% 25 6% 221 52% 423 100%

South 199 40% 50 10% 246 50% 495 100%

West 176 37% 41 9% 258 54% 475 100%

Sub Total 1100 44% 217 9% 1175 47% 2492 100%

Hyderabad 222 27% 108 13% 481 59% 811 100%

Grand Total 1322 40% 325 10% 1656 50% 3303 100%

Table 33: Status of Income and Expenditures in Households of Fully Immunized Children

Districts Debt No Debt No Saving Saving Total

# % # % # % # %

Central 214 64% 92 28% 26 8% 332 100%

East 250 56% 177 40% 18 4% 445 100%

Korangi 199 62% 113 35% 10 3% 322 100%

Malir 299 71% 108 26% 16 4% 423 100%

South 218 44% 262 53% 15 3% 495 100%

West 321 68% 142 30% 12 3% 475 100%

Sub Total 1501 60% 894 36% 97 4% 2492 100%

Hyderabad 396 49% 367 45% 48 6% 811 100%

Grand Total 1897 57% 1261 38% 145 4% 3303 100%

Table 34: Education level of Mothers of Fully immunized Children

# of School Years 0 (Illiterate) 01-05 06-10 11-15 15+ Grand Total

# % # % # % # % # % # %

Central 112 34% 43 13% 126 38% 48 14% 4 1% 333 100%

East 196 44% 85 19% 119 27% 39 9% 1 0% 445 100%

Korangi 135 42% 52 16% 108 34% 25 8% 2 1% 322 100%

Malir 240 57% 81 19% 83 20% 19 4% 0 0% 423 100%

South 176 35% 85 17% 193 39% 0 0% 42 8% 496 100%

West 167 35% 65 14% 171 36% 69 15% 3 1% 475 100%

Sub Total 1026 41% 411 16% 800 32% 200 8% 52 2% 2494

100%

Hyderabad 542 67% 141 17% 52 6% 74 9% 2 0% 811 100%

Grand Total 1568 47% 552 17% 852 26% 274 8% 54 2% 3305

100%

Denominator is 3305 (total number of mothers of fully immunized children)

Table 35: Number of Rooms Districts Zero Dose Fully Immunized

1 2--3 4--6 7-10+ Total 1 2--3 4--6 7-10+ Total

# % # % # % # % # % # % # % # % # % # %

Central 25 68% 12 32% 0 0% 0 0% 37 100% 143 43% 162 49% 26 8% 1 0% 332 100%

East 29 64% 15 33% 1 2% 0 0% 45 100% 262 59% 162 36% 21 5% 0 0% 445 100%

Korangi 20 74% 7 26% 0 0% 0 0% 27 100% 200 62% 110 34% 12 4% 0 0% 322 100%

Malir 46 51% 42 46% 3 3% 0 0% 91 100% 218 52% 190 45% 15 4% 0 0% 423 100%

South 12 57% 7 33% 1 5% 1 5% 21 100% 250 51% 219 44% 24 5% 2 0% 495 100%

West 17 63% 9 33% 1 4% 0 0% 27 100% 247 52% 187 39% 36 8% 5 1% 475 100%

Sub Total 149 60% 92 37% 6 2% 1 0% 248 100% 1320 53% 1030 41% 134 5% 8 0% 2492 100%

Hyderabad 80 56% 56 39% 7 5% 0 0% 143 100% 340 42% 411 51% 58 7% 2 0% 811 100%

Grand Total

229 59% 148 38% 13 3% 1 0% 391 100% 1660 50% 1441 44% 192 6% 10 0% 3303 100%

Mothers

Table 36: Age Range of Interviewed Mothers

Districts 14-19 20-24 25-29 30-34 35-39 40+ Total

# % # % # % # % # % # % # %

Central 20 3% 135 20% 207 31% 189 29% 100 15% 15 2% 666 100%

East 25 3% 159 19% 324 38% 226 27% 90 11% 19 2% 843 100%

Korangi 19 3% 125 22% 227 40% 138 24% 57 10% 2 1% 568 100%

Malir 19 2% 155 19% 328 39% 264 31% 64 31% 12 1% 842 100%

South 27 3% 147 18% 366 43% 206 25% 84 10% 13 1% 843 100%

West 22 2% 228 27% 310 37% 201 24% 66 8% 16 2% 843 100%

Sub Total 132 3% 949 21% 1762 38% 1224 27% 461 10% 77 2% 4605 100%

Hyderabad 20 2% 320 23% 459 34% 395 29% 141 10% 30 2% 1365 100%

Grand Total 152 3% 1269 21% 2221 37% 1619 27% 602 10% 107 2% 5970 100%

48

Table 37: Years of Schooling Attended by Mothers

Districts 0 1-5 6-10 11-15 15+ Total

# % # % # % # % # % # %

Central 303 45% 89 13% 196 30% 71 11% 7 1% 666 100%

East 461 55% 129 15% 188 22% 58 7% 7 1% 843 100%

Korangi 298 52% 84 15% 151 27% 33 6% 2 0% 568 100%

Malir 552 66% 134 16% 130 15% 26 3% 0 0% 842 100%

South 367 44% 142 17% 277 33% 55 7% 2 0% 843 100%

West 366 43% 122 14% 257 31% 93 11% 5 1% 843 100%

Sub Total 2347 51% 700 15% 1199 26% 336 8% 23 0% 4605 100%

Hyderabad 976 72% 227 17% 65 4% 94 7% 3 0% 1365 100%

Grand Total 3323 56% 927 16% 1264 20% 430 8% 26 0% 5970 100%

Denominator is 5970 (total number of mothers interviewed)

Table 38: Mothers Engaged in Livelihood Activities

Districts Yes No Total

# % # % # %

Central 61 9% 605 91% 666 100%

East 138 16% 705 84% 843 100%

Korangi 31 5% 537 95% 568 100%

Malir 18 2% 824 98% 842 100%

South 55 7% 788 93% 843 100%

West 51 6% 792 94% 843 100%

Sub Total 354 8% 4251 92% 4605 100%

Hyderabad 61 5% 1304 96% 1365 100%

Grand Total 415 7% 5555 93% 5970 100%

Table 39: Number of Children of Each Mother of Less Than 2 Year of Age

Districts 1 2 3 Total

# % # % # % # %

Central 664 99% 2 1% 0 0% 666 100%

East 839 99% 4 1% 0 0% 843 100%

Korangi 568 100% 0 0% 0 0% 568 100%

Malir 839 99% 3 1% 0 0% 842 100%

South 838 99% 5 1% 0 0% 843 100%

West 837 99% 6 1% 0 0% 843 100%

Sub Total 4585 100% 20 0% 0 0% 4605 100%

Hyderabad 1365 100% 0 0% 0 0% 1365 100%

Grand Total 5950 100% 20 0.3% 0 0% 5970 100%

Table 40: Vaccination Protect from Diseases- Knowledge Level of Mothers

Districts To Protect from Disease Other Purpose Do Not Know Total

# % # % # % # %

Central 294 44% 18 3% 354 53% 666 100%

East 322 38% 120 14% 401 48% 843 100%

Korangi 271 48% 36 6% 261 46% 568 100%

Malir 272 32% 59 7% 514 61% 842 100%

South 423 50% 45 5% 375 44% 843 100%

West 400 47% 61 7% 382 45% 843 100%

Sub Total 1982 43% 339 7% 2287 50% 4605 100%

Hyderabad 600 44% 100 7% 665 49% 1365 100%

Grand Total 2582 43% 439 7% 2952 49% 5970 100%

Table 41: Preferred Sources of Information for Mothers

Districts T.V Radio Poster/Bill board Leaflet Health Worker Others

# % # % # % # % # % # %

Central 396 63% 56 9% 178 28% 49 8% 134 21% 286 45%

East 307 38% 84 10% 123 15% 28 3% 298 37% 581 72%

Korangi 185 34% 2 0.40% 12 2% 14 3% 29 5% 402 74%

Malir 164 22% 5 1% 32 4% 17 2% 146 19% 617 82%

South 407 50% 46 6% 135 16% 44 5% 146 18% 415 50%

West 470 57% 26 3% 192 23% 41 5% 92 11% 462 56%

Sub Total 1929 44% 219 5% 672 15% 193 4% 845 19% 2763 63%

Hyderabad 1155 86% 168 12% 154 11% 104 8% 1132 84% 209 15%

Grand Total 3084 54% 387 7% 826 14% 297 5% 1977 35% 2972 52%

Multiple Answers were Recorded

49

Table 42: Knowledge of Mothers About Working of Lady Health Workers (LHWs)

Districts Mothers having knowledge Mothers not having knowledge Total

# % # % # %

Central 260 39% 406 61% 666 100%

East 364 43% 479 57% 843 100%

Korangi 83 15% 485 85% 568 100%

Malir 246 29% 596 71% 842 100%

South 131 16% 712 84% 843 100%

West 87 10% 756 90% 843 100%

Sub Total 1171 25% 3434 75% 4605 100%

Hyderabad 1350 99% 15 1% 1365 100%

Grand Total 2521 42% 3449 58% 5970 100%

Table 43: Types of Services Provided by LHWs in Slums Types of Work Central East Korangi Malir South West Sub Total Hyderaba

d Total

# % # % # % # % # % # % # % # % # % Promote Health Education

210 32% 249 30% 64 12% 184 22% 86 10% 81 9% 874 19% 1063 78% 1937 32%

Supply Family Planning Products

1 0.20% 10 1% 8 1% 18 2% 19 2% 6 1% 62 1% 85 6% 147 2%

Give Guidance About Treatment of Illness

1 0.20% 0 0% 0 0% 0 0% 0 0% 0 0% 1 0% 38 3% 39 1%

Refer to Hospital 14 2% 6 1% 2 0.20% 1 0% 6 1% 0 0% 29 1% 6 0.40% 35 1%

Vaccinate/ Help Vaccinator

32 5% 96 11% 3 0% 0 0% 13 2% 0 0% 144 3% 156 11% 300 5%

Information about Immunization

0 0% 0 0% 0 0% 37 4% 0 0% 0 0% 37 1% 0 0% 37 1%

Don’t Know 2 0.20% 3 0% 6 1% 6 1% 7 1% 0 0% 24 1% 2 0.10% 26 0%

Not Applicable 406 61% 479 57% 485 85% 596 71% 712 84% 756 90% 3434 75% 15 1% 3449 58%

Grand Total 666 100% 843 100% 568 100% 842 100% 843 100% 843 100% 4605 100% 1365 100% 5970 100%

Table 44: Availability of EPI Facility


# % # % # %

Central 80 12% 586 88% 666 100%

East 121 14% 722 86% 843 100%

Korangi 118 21% 450 79% 568 100%

Malir 91 11% 751 89% 842 100%

South 138 16% 705 84% 843 100%

West 134 16% 709 84% 843 100%

Sub Total 682 15% 3923 85% 4605 100%

Hyderabad 30 2% 1335 98% 1365 100%

Grand Total 712 12% 5258 88% 5970 100%

Table 45: Most Commonly Used EPI services (multiple Responses)

Districts Fixed EPI Facility

Outreach Vaccination services

Lady Health Worker

Private Facility Doctor

Others Total

# % # % # % # % # % # %

Central 505 76% 190 29% 13 2% 130 20% 65 10% 903 136%

East 571 68% 260 31% 58 7% 72 9% 63 7% 1024 121%

Korangi 527 93% 96 17% 0 0% 6 1% 0 0% 629 111%

Malir 698 83% 175 21% 0 0% 24 3% 0 0% 897 107%

South 757 90% 131 16% 12 1% 62 7% 22 3% 984 117%

West 757 90% 131 16% 12 1% 62 7% 22 3% 984 117%

Sub Total 3815 83% 983 21% 95 2% 356 8% 172 4% 5421 118%

Hyderabad 1057 77% 300 22% 144 11% 31 2% 18 1% 1550 114%

Grand Total 4872 82% 1283 21% 239 4% 387 6% 190 3% 6971 117%

50

Household Coverage

Table 46: Units of Analysis in the Survey

Districts Households Mothers Children

Central 661 666 668

East 843 843 847

Korangi 567 568 568

Malir 842 842 845

South 842 843 848

West 842 843 849

Sub Total 4597 4605 4625

Hyderabad 1365 1365 1365

Grand Total 5962 5970 5990

Table 47: Total Family Members with Gender Segregation

Districts Total Household Members Male Female

# % # %

Central 4446 2263 51% 2183 49%

East 5524 2772 50% 2752 50%

Korangi 3496 1814 52% 1682 48%

Malir 5671 2886 51% 2755 49%

South 5326 2671 50% 2655 50%

West 5339 2657 50% 2682 50%

Sub Total 29802 15063 51% 14709 49%

Hyderabad 10641 5306 50% 5335 50%

Grand Total 40443 20369 50% 20044 50%

Table 48: Average Family Size

Districts Average Family Size Average Male Members Average Female Members

Central 7 3.4 3.3

East 7 4 3

Korangi 6 3 3

Malir 7 3.4 3.3

South 6 3 3

West 6 3 3

Sub Total 7 4 3

Hyderabad 8 4 4

Grand Total 8 4 4

Table 49: Number of Members in House Including Guests the Day Before

Districts 1-5 6-10 11-20 21-30 31-40+ Total

# % # % # % # % # % # %

Central 246 37% 333 50% 76 12% 5 0.80% 1 0.20% 661 100%

East 366 43% 387 46% 85 10% 5 1% 0 0% 843 100%

Korangi 241 43% 294 52% 30 5% 2 0.40% 0 0% 567 100%

Malir 328 39% 430 51% 81 10% 2 0% 1 0% 842 100%

South 382 45% 396 47% 61 7% 3 1% 0 0% 842 100%

West 408 49% 344 41% 79 9% 8 1% 3 0% 842 100%

Sub Total 1971 43% 2184 48% 412 9% 25 1% 5 0% 4597 100%

Hyderabad 461 34% 642 47% 230 17% 27 2% 5 0.4% 1365 100%

Grand Total 2432 41% 2826 47% 642 11% 52 1% 10 0% 5962 100%

Table 50: Years of Stay in Slums

Districts 0-Less than 2 Years 2-5 years 6-15 years 15+ years Total

# % # % # % # % # %

Central 92 14% 164 25% 198 30% 207 31% 661 100%

East 141 17% 230 27% 319 38% 153 18% 843 100%

Korangi 64 11% 164 29% 276 49% 63 11% 567 100%

Malir 80 9% 199 24% 440 52% 123 15% 842 100%

South 78 9% 216 26% 396 47% 152 18% 842 100%

West 115 14% 232 28% 259 30% 236 28% 842 100%

Sub Total 570 12% 1205 26% 1888 42% 934 20% 4597 100%

Hyderabad 51 4% 159 12% 552 40% 603 44% 1365 100%

Grand Total 621 10% 1364 23% 2440 41% 1537 26% 5962 100%

51

Table 51: Reasons for Less than Two Years of Stay

Districts

To find a Job/Better Life

Came from conflict affected area

Displaced temporarily

Nomads Other Living here for more than 2 years

Total

# % # % # % # % # % # % # %

Central 50 8% 5 1% 39 6% 0 0% 3 0% 564 85% 661 100%

East 55 7% 4 0% 40 5% 0 0% 42 5% 702 83% 843 100%

Korangi 6 1% 1 0% 22 4% 0 0% 35 6% 503 89% 567 100%

Malir 11 1% 4 0% 15 2% 0 0% 50 6% 762 90% 842 100%

South 20 2% 4 0% 38 5% 0 0% 16 2% 764 91% 842 100%

West 7 1% 3 0% 47 6% 0 0% 58 7% 727 86% 842 100%

Sub Total 149 3% 21 0.5% 201 4% 0 0% 204 4% 4022 87% 4597 100%

Hyderabad 21 2% 6 0.4% 16 1% 0 0% 15 1% 1307 96% 1365 100%

Grand Total 170 3% 27 0.5% 217 4% 0 0% 219 4% 5329 89% 5962 100% *Note: Others include Rental house, bought own house. Personal matters (separated from in-laws, divorced) etc

Table 52: Housing Structures


# % # % # % # %

Central 206 31% 23 4% 432 65% 661 100%

East 123 14% 268 32% 452 54% 843 100%

Korangi 32 6% 249 44% 286 50% 567 100%

Malir 586 70% 28 3% 228 27% 842 100%

South 32 3% 451 54% 359 43% 842 100%

West 18 2% 369 44% 455 54% 842 100%

Sub total 997 22% 1388 30% 2212 48% 4597 100%

Hyderabad 117 9% 664 49% 584 43% 1365 100%

Grand Total 1114 19% 2052 34% 2796 47% 5962 100%

Table 53: Commonly Spoken Language

Districts Urdu Punjabi Potohari Balochi Pashto Sindhi Siraiki Others Total

# % # % # % # % # % # % # % # % # %

Central 170 26% 124 19% 13 2% 37 6% 151 23% 48 7% 61 9% 57 9% 661 100%

East 118 14% 156 19% 0 0% 44 5% 91 11% 202 24% 148 18% 84 10% 843 100%

Korangi 128 23% 105 19% 0 0% 35 6% 117 21% 82 14% 10 2% 90 16% 567 100%

Malir 119 14% 77 9% 3 0% 147 17% 101 12% 337 40% 37 4% 21 2% 842 100%

South 209 25% 118 14% 0 0% 183 22% 136 16% 70 8% 47 6% 79 9% 842 100%

West 273 32% 38 5% 2 0% 109 13% 188 22% 86 10% 30 4% 116 14% 842 100%

Sub Total 1017 22% 618 13% 18 0% 555 12% 784 17% 825 18% 333 7% 447 10% 4597 100%

Hyderabad 287 21% 52 4% 2 0% 54 4% 38 3% 606 44% 135 10% 191 14% 1365 100%

Grand Total 1304 22% 670 11% 20 0% 609 10% 822 14% 1431 24% 468 8% 638 11% 5962 100%

Table 54: Number of Rooms per House

Districts 1 2-3 4-6 7-10 10+ Total

# % # % # % # % # % # %

Central 317 48% 301 45% 39 6% 4 1% 0 0% 661 100%

East 496 59% 309 37% 38 4% 0 100% 0 0% 843 100%

Korangi 358 64% 194 33% 15 3% 0 0% 0 0% 567 100%

Malir 435 52% 380 45% 26 3% 1 0% 0 0% 842 100%

South 442 52% 362 43% 33 4% 5 1% 0 0% 842 100%

West 491 58% 292 35% 53 6% 5 1% 1 0% 842 100%

Sub total 2539 55% 1838 40% 204 4% 15 0% 1 0% 4597 100%

Hyderabad 648 48% 632 46% 82 6% 3 0.20% 0 0% 1365 100%

Grand Total 3187 53% 2470 41% 286 5% 18 0% 1 0% 5962 100%

Table 55: Availability of Electricity


# % # % # %

Central 625 95% 36 5% 661 100%

East 820 97% 23 3% 843 100%

Korangi 558 98% 9 2% 567 100%

Malir 758 90% 84 10% 842 100%

South 834 99% 8 1% 842 100%

West 841 100% 1 0% 842 100%

Sub Total 4436 96% 161 4% 4597 100%

Hyderabad 1321 97% 44 3% 1365 100%

Grand Total 5757 97% 205 3% 5962 100%

52

Table 56: Sources of Water

Districts Government Ground Water Other Sources Total

# % # % # % # %

Central 431 65% 203 31% 27 4% 661 100%

East 623 74% 157 19% 63 7% 843 100%

Korangi 291 51% 215 38% 61 11% 567 100%

Malir 630 75% 112 13% 100 12% 842 100%

South 597 71% 188 22% 57 7% 842 100%

West 398 47% 200 24% 244 29% 842 100%

Sub Total 2970 65% 1075 23% 552 12% 4597 100%

Hyderabad 1005 74% 354 26% 6 0% 1365 100%

Grand Total 3975 67% 1429 24% 558 9% 5962 100%

Table 57: Duration of Water Availability in Case of Government Water Supply

Districts Less than 1 hour 1-5 hours 6-10 hours 11-15 hours 16-20 hours 20+ Hours Total

# % # % # % # % # % # % # %

Central 121 28'% 253 58'% 6 1.4'% 2 0.4'% 1 0.2'% 48 11% 431 100%

East 185 30% 217 35% 62 10% 48 8% 14 2% 97 15% 623 100%

Korangi 77 27% 152 52% 18 6% 24 8% 4 1% 16 6% 291 100%

Malir 371 59% 164 26% 27 4% 17 3% 10 2% 41 6% 630 100%

South 140 49% 293 49% 32 5% 18 4% 4 1% 110 18% 597 100%

West 311 78% 4 1% 82 21% 1 0% 0 0% 0 0% 398 100%

Sub Total 1205 41% 1083 36% 227 8% 110 4% 33 1% 312 11% 2970 100%

Hyderabad 2 0% 569 58% 192 19% 91 9% 151 15% 0 0% 1005 100%

Grand Total 1207 30% 1652 42% 419 11% 201 5% 184 5% 312 8% 3975 100%

Denominator is 3975 (houses where government water supply available)

Table 58: Types of Toilets

Districts Connected with Street Drain Traditional/ Open Pit Houses Without Toilets Total

# % # % # % # %

Central 635 96% 0 0% 26 4% 661 100%

East 778 92% 16 2% 49 6% 843 100%

Korangi 530 93% 27 5% 10 2% 567 100%

Malir 669 80% 130 15% 43 5% 842 100%

South 826 98% 2 0% 14 2% 842 100%

West 794 94% 39 5% 9 1% 842 100%

Sub Total 4232 92% 214 5% 151 3% 4597 100%

Hyderabad 668 49% 583 43% 114 8% 1365 100%

Grand Total 4900 82% 797 13% 265 4% 5962 100%

Table 59: Average Number of People using One Toilet

Districts

Central 6

East 6

Korangi 6

Malir 6

South 6

West 6

Sub Total 6

Hyderabad 7

Grand Total 7

Table 60: Modes of Defecation in the Case of Unavailability of Toilet

Districts Neighbor’s Toilet Public Toilet Open Defecation Houses With Toilets Total

# % # % # % # % # %

Central 1 0% 1 0% 24 4% 635 96% 661 100%

East 3 1% 0 0% 46 5% 794 94% 843 100%

Korangi 0 0% 10 2% 0 0% 557 98% 567 100%

Malir 5 1% 37 4% 1 0% 799 95% 842 100%

South 0 0% 4 0% 10 2% 828 98% 842 100%

West 8 1% 0 0% 1 0% 833 99% 842 100%

Sub Total 17 0.4% 52 1% 82 2% 4446 97% 4597 100%

Hyderabad 17 1% 10 1% 87 6% 1251 92% 1365 100%

Grand Total 34 1% 62 1% 169 3% 5697 96% 5962 100%

53

Table 61: Sources of Income

Districts Job (Government Job, Private Job, Work in Foreign Country)

Small Enterprise Daily Wage Worker Total

# % # % # % # %

Central 301 46% 86 13% 274 41% 661 100%

East 292 35% 71 8% 480 57% 843 100%

Korangi 306 54% 47 9% 214 37% 567 100%

Malir 308 37% 76 9% 458 54% 842 100%

South 306 36% 78 9% 458 55% 842 100%

West 275 33% 68 8% 499 59% 842 100%

Sub Total 1788 39% 426 9% 2383 52% 4597 100%

Hyderabad 321 24% 183 13% 861 63% 1365 100%

Grand Total 2109 35% 609 10% 3244 54% 5962 100%

Table 62: Economic Situation of Households

Districts Debt No Debt, No Savings Savings Total

# % # % # % # %

Central 415 63% 203 31% 43 6% 661 100%

East 532 63% 279 33% 32 4% 843 100%

Korangi 361 64% 186 33% 20 3% 567 100%

Malir 578 69% 222 26% 42 5% 842 100%

South 396 47% 419 50% 27 3% 842 100%

West 600 71% 227 27% 15 2% 842 100%

Sub Total 2882 63% 1536 33% 179 4% 4597 100%

Hyderabad 682 50% 611 45% 72 5% 1365 100%

Grand Total 3564 60% 2147 36% 251 4% 5962 100%

Documents

Acknowledgements - UNICEF