“Amma Jee, if you don’t get your grandchildren vaccinated, they will fall ill. Then who will look after them? You have to complete the immunisation schedule if you want them protected against the diseases.”

Draped in a black abaya, hijab wrapped around her small face, Nasira Ehsan, the young Community Health Worker tries to convince a caregiver in a slum in Union Council 110, Thokar Niaz Baig, Lahore.

Often tending to three grandchildren while their mother is at work, the old woman is genuinely concerned about who will take care of the children when they fall ill. She tries to explain her reasons for not vaccinating them.

The immunisation schedule Ehsan refers to is a set of inoculations, given from birth to the age of 15 months. Completing the schedule protects children under 23 months from 10 diseases that are preventable through vaccines, such as tuberculosis, polio, diphtheria, pertussis (whooping cough), tetanus, haemophilus influenza type B, hepatitis B, diarrhoea, pneumonia, and measles.

The woman’s justifications for not vaccinating her grandchildren do not surprise Ehsan. Misconceptions and misinformation around vaccination are an issue she has to face in her work every day. However, she perseveres and tries to convince the woman that her fears are unfounded and the benefit of overcoming them is a life free of disease for her grandchildren.

Communities in these slums have little or no awareness of the benefits of childhood immunisation. They believe that the vaccinations cause sickness and other side effects. They find validation for this stance when a child falls ill after receiving a shot.

Words fail to articulate the plight of those living in these slums: plastic bags burn in the sun, and children in rags roam barefoot in the mud and play on the garbage dumps, their blonde ginger hair showing clear signs of malnourishment. Women with sunburnt skin are busy mending their tented houses, returning to their normal after the rain. These huts have no boundary walls or fencings. Not knowing who is living where. Rain is never a blessing here; it’s always a curse.

Representing half of the country, the Punjab has the highest number of fully immunised children, more than 80 percent (PDHS 2017/18) compared to the national average of 66 percent.

While immunisation progress in the Punjab is encouraging, coverage varies substantially within the province and from one district to another. There is a lot that isn’t under the radar, these slums located in nooks and corners of urban centres are one such example.

Lahore, the economic hub of the province, is the second most populous city of Pakistan with a population exceeding 11.5 million according to the 2017 census. Almost half of the people here are economic migrants who come here from various districts in search of better livelihoods. A large number of these people reside in urban slums.

Ehsan and her team of female Community Health Workers have been working in the slums for the last year. In a profiling exercise conducted by her organisation, Civil Society Human and Institutional Programme, revealed that around 4.6 million people live in slums and underserved areas.

Unable to afford housing in the planned area of city, they construct temporary settlements and eventually start living in them. Not recognized by the government, there are unauthorized temporary settlements mostly constructed on ‘illegally occupied’ land.

That is the reason these katchi abadis or slums are mostly found around railway lines, under the bridges, along storm drains, or in peripheries of housing colonies for low-income people.

Faced with several inequalities, communities living in slums are deprived of all basic amenities. There is no running water, toilets, gas or electricity. No access to healthcare facilities and no solid or liquid waste management systems. The living conditions in these ‘human settlements’ are far from humane.

Although, all vaccines in the RI schedule are provided free of cost by Punjab Expanded Programme on Immunisation (EPI) in all public health facilities, the children in these slums do get the coverage they deserve. There is also a supply and demand issue.

This is probably the reason why Ehsan’s organisation, with support from the provincial EPI, decided to improve immunisation coverage and create demand for essential immunisation.

The work is challenging. Going door to door, to check the vaccination status of the children living in these houses, the team profiled all 12 slums falling under the Union Council Thokar Niaz Baig.

Words fail to articulate the plight of those living in these slums: plastic bags burn in the sun, and children in rags roam barefoot in the mud and play on the garbage dumps, their blonde ginger hair showing clear signs of malnourishment.

They collected information not only on the immunisation status of children but also details of the population residing, the state of access to utilities (electricity, gas), sanitation and drinking water.

Some difficult cases of vaccine refusal required bringing in local councillors and religious leaders.

Out of the total population of around 10,000 living in these slums, 1,147 (or 11 percent) children under two years of age were vaccinated. This increased the overall level of fully immunised children. The community was connected with vaccinators and the local health committee made these slums a part of Health Department plan and linked it with the nearest BHU for smooth service delivery of immunisation on continuous basis.

Diving deeper into the data collected by the civil society on major reasons for unimmunised children, revealed that in 87 percent cases low awareness and lack of information about benefits of vaccination were cited by the parents. Communities living in the slums do not realise the importance of vaccination or the need for completing a vaccination schedule. Vaccination cards are often misplaced which also results in discontinuation of the immunisation process.

Along with lack of information on the need for vaccinations, misinformation and misconceptions are also rampant. Communities believe that vaccinations cause infertility and sickness, and are part of a western agenda. Or they believe that immunisation is prohibited by religion, and vaccinating pregnant mothers can lead to interference in childbirth with negative consequences for both the mother and the child.

Another significant reason cited was competing priorities: With both parents often heavily committed to their daily activities to make ends meet, the issue of getting their children immunised is put on the backburner, especially in cases where women have to manage the household alone as well as contribute to the income. Moreover, most slums did not have easy access to a proper EPI facility. The long distances, limited transport facility and the cost associated with it are a burden on these communities.

The non-stop massive movement of population from villages to the cities has continued with no tangible increase in resources to meet this growing challenge of health needs. Urban health, especially immunisation in urban slums, has been identified as the next big challenge for ending preventable child deaths.

For far too long, people have argued that keeping the citizens healthy was only the job of government. Civil society organisations have been working at the community level accessing people, especially beyond the reach of direct government services. Experts now say that active engagement with civil society can help achieve optimum results inducing ownership and sustainability of the programme run by governments. Importantly, they can help reach the unreached.

As the world gears up to observe the World Immunisation Week (24–30 April) 2020, we need some serious introspection to ensure that all children living in the remotest and marginalised communities have access to immunisation and are reached by those providing vaccines.