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Improving Immunization Coverage in Pakistan

At GIF our mission is to find, fund, and scale-up cost-effective, evidence-based innovations with the potential to measurably improve the lives of millions of people living on $5 a day or less in the developing world. We back promising innovations early on as they set out to build their evidence base.

As part of this approach, we are supporting Interactive Research and Development (IRD) to help set up a three-year randomized control trial in Karachi, Pakistan, which will aim to find the optimal incentive amount, schedule, and design needed to achieve high immunization rates in a cost-effective way. In this guest blog, the team at IRD explain why increasing rates of immunization is so important and how the study will work.

Despite immunization being one of the most cost-effective ways to improve child survival, 18.7 million children across the world – equivalent to one in every five – remain unvaccinated. Over two million children die from vaccine-preventable diseases each year, particularly in low- and middle-income countries.

Many different strategies have been used, with mixed success, to increase uptake of immunization services including health education and communication interventions. Government efforts to address this challenge have typically focused on improving supply and distribution systems. Helping busy moms make this a priority is a key ingredient too.

According to recent evaluations, providing cash or in-kind incentives has the potential to increase take-up and completion rates of immunization in developing countries. In Latin America, for instance, conditional cash transfer (CCT) programs in Brazil, Mexico and Columbia showed improved health and immunization outcomes for beneficiaries.

These well-studied CCTs were of large amount. We know less about small financial “nudges”. We know that when moms are promised small bags of lentils and assured that nurses will be there they show up at vaccination camps. Is there a way to get this kind of result cheaply, and sustainably, in a busy urban setting?

Despite small incentives remaining potentially attractive to policymakers, there are two major constraints which make scale-up challenging. The first is uncertainty about the most cost‐effective way to structure these incentives in terms of size, schedule, and design (e.g. lottery vs non‐lottery approaches), and the second is the challenge of delivering small incentives in a way that is inexpensive, logistically simple, and not subject to leakage.

To address these gaps and generate evidence on the impact of CCTs, Interactive Research and Development (IRD), in collaboration with research partners, is conducting a three- year experimental study testing to determine the optimal CCT amount, design and schedule for achieving a higher immunization rate in the most cost-effective way.

Based in Karachi, the study will enrol 9,600 children under two years of age in 10 different study arms. IRD will vary the incentive amount (low versus high incentives), incentive schedule (flat versus sharply increasing incentives) and incentive design (lottery versus sure payments) and compare the resulting immunization rates of children across the treatment arms. The study will use IRD’s Zindagi Mehfooz (ZM) platform, which utilizes an Android phone-based immunization registry to record and analyze program data in real time, and mobilize the entire community by engaging parents via interactive SMS communication.

Children will be enrolled in the immunization registry upon visiting their immunization center and will be randomly allocated to one of the several study arms. Once the child is immunized, the associated pay-out will be calculated by the ZM Registry and disbursed to the parent’s National Identity Card. Following successful biometric verification of the caregiver at any one of the 70,000+ Easypaisa shops (the largest network of mobile money transfers) across Pakistan, the incentive can then be cashed. This mechanism offers an easy, reliable and transparent mechanism to disburse incentives, minimizing the risk of corruption and associated leakages.

Small scale conditional cash transfers present a promising approach to increasing immunization coverage, specifically among low- and middle-income countries, and warrants further evaluation. This study is an attempt to do just that –  it will generate key findings for policy-makers regarding the most optimal and cost-effective way both of structuring small incentives and enhancing state capacity to deliver these incentives.