It’s the last ball of the match, Bilal’s team needs two runs to win. The captain and the bowler have a discussion and make some last minute changes to the field. The bowler returns to his mark, and starts his run up. Bilal squirms in his seat, beads of perspiration on his brow. Cricket has always meant so much to him. The bowler crosses the umpire and delivers the ball: it’s a low full toss, the batsman, a friend of Bilal’s, pushes the ball towards long on and rushes to get the two runs, a fielder moves in to pick the ball, the batsmen turns for the second – everything happens in the blink of an eye – the ball hits the wicket, is he in or out? Everybody turns to the umpire, “in”, he says – and the celebrations begin.
All the boys waiting by the boundary rush to congratulate their friends, except Bilal. He sits on the side, unable to join in the celebrations, because he can’t run that fast. In fact, he cannot run at all because he has polio, an infectious and completely preventable disease.
Polio is one of the most worrying childhood diseases in Pakistan. It is one of the diseases that parents fear most because it can cripple a healthy, able-bodied child. A few days after being infected by the polio virus, muscle stiffness, nausea and fever breaks out in the human body. In severe cases, such as Bilal’s, there is paralysis of the muscles leading to a permanent disability.
To date, Pakistan is one of only two countries in the world where children are still being infected by the polio virus.
The Expanded Program on Immunization (EPI) in Pakistan is responsible for coordinating and overseeing all immunization efforts in the country. According to EPI, 27% of deaths in children under the age of five are due to diseases that can be prevented through easily available vaccinations. These diseases include Poliomyelitis (also known as Polio), Neonatal Tetanus, Measles, Diphtheria, Pertussis (Whooping Cough), Hepatitis-B, Hib Pneumonia, Meningitis and Childhood Tuberculosis.
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In the past the disease has persisted in Pakistan because of a disinformation campaign by the Taliban to halt immunizations, mistrust by some minority groups and vaccinators struggle to reach remote areas.
To fulfill their mission of vaccinating every child in the country, EPI decided to revamp their strategy and address vulnerabilities within the program itself. These challenges included less geographic coverage and low performance of field vaccinators.
To solve this, EPI enlisted the help of the Punjab Information Technology Board (PITB), which made a digital system called E-Vaccs to monitor the attendance of all the vaccinators sent out into the field.
Under E-Vaccs, an immunization information system with an accompanying smartphone application for vaccinators was made, that also stored real-time immunization records onto a centralized database. The first E-Vacc application was launched in June 2014 in four districts of Punjab and it was rapidly rolled out to all 36 districts by October 2014.
Under this system, 3750 smartphones with the mobile application were provided to the field vaccinators in a bid to improve their attendance. Instead of signing paper registers at Basic Health Units (BHUs) as proof of attendance, vaccinators now had to sign-in three times a day. The first check-in is at their assigned location, the second at their kit stations which is usually a mosque or a house in the district and the third at the end of the day when they have to enter a vaccinator log on their smartphone application of how many children were vaccinated and which antigens had been used.
The sign-in is done by taking a picture of the kit station with the smartphone application. The pictures are geo-tagged and time stamped, providing foolproof evidence that the vaccinators are physically present at the location and have shown up to work.
The interesting thing is that after this immunization information system was implemented, the field vaccinators realized that their attendance could now be monitored more closely so attendance dropped sharply from 97% to 54%. This was because vaccinators knew that they could no longer send in a false attendance record. The accurate and verified attendance of vaccinators sent into the field steadily improved after this point.
“By using our smartphone application, the attendance of field vaccinators could now be monitored properly for the first time,” says Dr. Umar Saif, Chairman of PITB. “The result was that attendance improved drastically from a mere 36% to a staggering 94%.”
However, the low geographical coverage of the rural areas where the field workers had been able to vaccinate children remained the same. So PITB came up with a color-coded visualization technique through which they could look at all the vaccination coverage in different areas.
Initially, they made use of paper maps for each district to monitor areas that had little to no vaccination activity. The paper maps were made by extracting satellite imagery from Google Maps and overlaying the vaccinator GPS data obtained from the smartphone application over it. But printing these long 4 to 9 feet long maps proved to be costly. They were hard to transport and even harder to store.
“It was also difficult to identify population pockets in rural areas because the last census conducted by Pakistan was in 1998 and there is no recent population density map available,” says Maria Zubair, Geographic Information System (GIS) expert at PITB.
That’s when Dr. Mohsen Ali, a faculty member at Lahore’s Information Technology University (ITU), became involved and came up with an algorithm to analyze the satellite imagery, including segmenting out the human developed areas and identifying different landmarks, houses, roads and streets.
All this information was now digitized and made available on a dashboard.
EPI and the Executive District Officers (EDO) could now use these dashboards to see the broader overview of performance in each district, including each individual vaccinators activity and which areas had not been “covered” by the field workers for any reason. This new and improved system was dubbed E-Vacc-2 and was implemented throughout Punjab by October of 2015.
Using these initiatives, geographical coverage ended up increasing from 25% in 2014 to 88% in 2016. “We also looked at independent surveys conducted by AC Nielson and Punjab Health Survey to check antigen coverage for vaccine preventable diseases such as childhood tuberculosis, which showed that they had significantly improved from the previous two years,” says Zubair.
Now that the two main challenges had been resolved, EPI wanted to resolve immunization issues that remained at a smaller level. The completion of vaccination courses hadn’t improved; parents used to forget their children’s next vaccination dates and for diseases like measles, which have a significant time period between two vaccination dates, the drop-out rates were high.
Har Zindagi – Every Life Matters, a research project from ITU, put forward a proposal to improve completion of vaccination courses and make a friendlier user-interface for the immunization system. They beat 247 other applicants to win a grant of £250,000 by the Sub-National Governance Project for their research project.
Har Zindagi made the original application more accessible and improved efficiency in record generation by coming up with a redesigned immunization card for parents. Similar in design and color to a Pakistani passport so parents would keep it more carefully, the new immunization card contains a Near-Field Communication tag inside it that enables real-time information sharing between the card and the mobile application in the vaccinators smartphones once they are tapped together. This helps generate detailed digital records for each child, and helps field vaccinators rely upon the same data for all subsequent visits.
“We have included infographics in the card so it would be helpful for parents and would really serve to educate them regarding details of their child’s vaccination regimen,” says Amna Batool, Technical Lead at Har Zindagi. “Parents will be able to keep track of exactly which vaccination their 5-month old or 2-year old child needs.”
Robo-calling and SMS reminders for vaccination dates to parents have also been introduced. The pilot program of Har Zindagi is currently being tested in the districts of Sahiwal and Sheikhupura. If the results of the pilot are favorable, they will be scaled up to more districts of Punjab and eventually throughout the country.
In 2014, a staggering 294 cases of polio had been reported in Pakistan – the most in any country of the world. The following year, the number of cases dropped to 51 and in 2016, there were 19 reported cases in total. The World Health Organization says that it is “the lowest number of annual cases ever reported, from the fewest number of affected areas in the country.”
This technology-based initiative has also been implemented in the province of Khyber Pakhtunkhwa (KP) at the request of the KP government and has been running for the past six months. The Immunization Information System has also been launched recently in Balochistan, making this system operational in three out of four provinces in Pakistan.
“Our ultimate goal is to have a country where polio has been completely eradicated so no other child would have to go through what Bilal did. Every child deserves the right to be happy and healthy,” says Dr. Saif.