13 May 2020 Version

Review of Pakistan Polio Programme’s Community Based Vaccination Strategy

Conducted by the GPEI Hub from 1 March – 27 April 2020

Team members: Arshad Quddus (WHO), Jeff Partridge (BMGF), Shamsher Ali Khan (UNICEF),
Tommi Laulajainen (UNICEF) and Abdinoor Mohamed (CDC)

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Table of Contents
ABBREVIATIONS..................................................................................................................................................3
EXECUTIVE SUMMARY .........................................................................................................................................4
I. BACKGROUND....................................................................................................................................6
II. INTRODUCTION...................................................................................................................................7
2.1 Core reservoirs and geographic risk classification ........................................................................ 7
2.2 Supplemental immunization activities (SIAs) ................................................................................ 7
2.3 Objectives of the CBV review ........................................................................................................ 8
III. METHODOLOGY .................................................................................................................................8
3.1 Setting and Design ......................................................................................................................... 8
3.2 Desk review .................................................................................................................................... 9
3.3 Interviews, focus group discussions and online survey................................................................. 9
IV. FINDINGS ..........................................................................................................................................9
4.1 Desk Review ................................................................................................................................... 9
4.2 CBV and community engagement ...............................................................................................16
4.3 Cost analysis.................................................................................................................................17
4.4 Online survey ...............................................................................................................................19
4.5 Focus Group Discussion (FGDs) ...................................................................................................21
4.6 Community trust and demand ....................................................................................................23
V. DISCUSSION AND CONCLUSIONS...........................................................................................................24
VI. RECOMMENDATIONS.........................................................................................................................28
6.1 Recommendations on the Scale of the CBV strategy ..................................................................28
6.2 Recommendations on vaccination strategy options ...................................................................28
6.3 Recommendations on addressing the risks associated with CBV transition ...............................28
6.4 Recommendations on government leadership and oversight ....................................................29
6.5 Recommendations on CBV support for essential immunization.................................................29
6.6 Recommendations on transforming CBV to a more effective strategy ......................................29
VII. ACKNOWLEDGEMENTS.......................................................................................................................30

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Abbreviations
AFP Acute Flaccid Paralysis (Surveillance)
AS Area Supervisor
C4E Communication for Eradication
CBV Community Based Vaccination
cVDPV2 Circulating Vaccine-Derived Poliovirus Type-2
CHW Community Health Worker
CTC CHIP Training and Consulting Pvt Limited
DHCSO District Health Communication Support Officer
DHO District Health Officer
DDM Direct Disbursement Mechanism
ES Environmental Surveillance
FGD Focus Group Discussion
FLWs Frontline Workers
GPEI Global Polio Eradication Initiative
IMB Independent Monitoring Board
ICM Intra-Campaign Monitoring
KFCP Key Family Care Practises
KP Khyber Pakhtunkhwa
LQAS Lot Quality Assurance Sampling
MT Mobile Team
NEAP National Emergency Action Plan
NEOC National Emergency Operations Center
NIDs National Immunization Days
PCM Post-Campaign Monitoring
SHMA Sidat Hayder and Morshed Associates Pvt Limited
SHRUC Super High-Risk Union Council
SIA Supplementary Immunization Activity
SMT Special Mobile Team
TAG Technical Advisory Group (for polio eradication)
UC Union Council
UCCSO Union Council Communication Support Officer
UCMO Union Council Medical Officer
WPV1 Wild Poliovirus Type-1

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Executive Summary
The Pakistan Polio Programme’s 2020 National Emergency Action Plan (NEAP) has introduced a number
of interventions, innovations and modifications to respond to both persistent programmatic challenges
and new or unfolding epidemiological risks. One key strategic change outlined in the 2020 NEAP is the
refinement of the scope of areas implementing Community Based Vaccination (CBV) to address
concerns about the programme’s capacity to manage the current scale of CBV, as well as questions
about the need for CBV in all UCs of Tier 1 and in the selected Tier 2 districts where CBV is ongoing. In
addition, the size and scope of CBV today has increased the cost of the polio programme in Pakistan –
while CBV covers about 10% of the country’s <5 years target population, it accounts for more than 50%
of the programme’s operational costs. In response to these concerns, Pakistan’s National Emergency
Operations Center (NEOC) requested the GPEI Hub in Amman, Jordan, to review the CBV strategy.

Upon request from the Pakistan NEOC, the GPEI Hub assembled a 5-member CBV Review Team. The
review was conducted for all areas implementing CBV strategy within Sindh, Balochistan and Khyber
Pakhtunkhwa (KP) provinces. Both qualitative and quantitative data collection methods were used to
address the objectives. Documents and data were collected for desk review from the NEOC and from
key polio staff at national, provincial, district and UC levels through questionnaires, interviews and focus
group discussions. Given the travel limitations imposed by the ongoing COVID-19 pandemic, all work
was done remotely.

Overall Conclusions
• No vaccination strategy will succeed without an enabling environment. The CBV strategy can only
succeed if the programme addresses the inhibiting factors of sub-optimal government leadership,
management and accountability, partner staff coordination at field level and community trust and
demand.
• Government leadership at all levels is key to achieving polio eradication in Pakistan. The capacity
and ability of national and provincial governments to effectively respond to national public health
emergencies, through collaboration but under national leadership, has been demonstrated during
the ongoing COVID-19 response.
• Results from analysis of critical functions, advantages and disadvantages, and its potential role in
essential immunization and integrated services for underserved communities, demonstrate that the
CBV strategy is still relevant and good value for money provided it is implemented in selected areas.

Major Recommendations
• The Review Team endorses the 2020 NEAP plan to exclude 89 UCs in Karachi, 5 UCs in Peshawar
District and all Tier 2 districts from CBV strategy by June 2020.
• In addition, the Review Team recommends that the CBV strategy should be excluded from the entire
Khyber District and 3 tehsils of Killa Abdullah District, where CBV is largely implemented through
male workers, by December 2020 but not later than June 2021
• For Karachi, the Review Team recommends the CBV strategy should be limited to the 34 highest risk
UCs of Karachi by June 2021.
• The Review Team recommends the transition to Special Mobile Team (SMT) strategy for all UCs in
Tier 1 districts that are recommended above to be excluded from CBV strategy.
• The Review Team recommends the transition to Mobile Team (MT) strategy for all UCs in Tier 2
districts that are recommended above to be excluded of CBV strategy.

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• Strong leadership by national and provincial governments, ownership of district administration and
engagement of local influentials would be key elements of smoother and successful transition. As
such, respective Commissioners and DCs should be given detailed briefing on the need for scaling
down and strategy shift for further taking up with the community, and local political leadership and
community influencers be taken on board by the DCs.
• Government leadership at all levels is key to success. As such, Commissioners and Chief Secretaries
should provide regular oversight to the programme with focus on CBV areas and government should
ensure the placement of high-performing DCs in CBV districts. Learning lessons from the COVID-19
experience, the District Administration in CBV areas should be driving and leading the PEI activities
and conducting critical reviews of each SIA.
• Recent management review of the programme recommended transformative changes in the
structure, processes, people and data system. The programme should accelerate the roll-out of
these recommendations to turn around the situation in CBV areas.
• As per their TORs, between campaign days CBV staff should focus on referral of under/unimmunized
children to EPI centers, identification and referral of newborns and support of EPI teams in tracking
of defaulters.

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I. Background
Following an explosive outbreak in 2014, the Pakistan polio programme shifted to a government-led,
‘one team’ approach, aligning partner support within the multidisciplinary, multi-agency initiative to
transform it into a truly data-driven programme that succeeded in reducing transmission in much of the
country. However, by late 2018, progress plateaued, and in 2019 transmission of WPV1 increased in
intensity and geographic spread and cVDPV2 emerged (Figure 1), as indicated by both AFP acute flaccid
paralysis (AFP) surveillance and environmental surveillance. While surveillance data indicates that the
peak in WPV1 transmission may have occurred in December 2019, widespread transmission of WPV1 is
ongoing and cVDPV2 is spreading geographically in 2020. As of 30 April 2020, 47 WPV1 cases and 45
cVDPV2 cases have been reported in 2020.

In their November 2019 report, the

Independent Monitoring Board
(IMB) described the resurgence of
cases in 2019 as a crisis, with “as
yet, no clear and credible route
back to the path of eradication.”1
The Technical Advisory Group
(TAG) on Polio Eradication
reviewed Pakistan’s situation in
August 2019 and concluded that
the programme was on a failing
trajectory, mainly due to
management failure at each level
(national / provincial / district / UC Figure 1: WPV1 & cVDPV2 cases, 2014-2020 (as of 5/5/2020)
levels), and failure to build community
trust and lack of high-quality programme activities.2 The TAG recommended transformational changes
to put the programme back on track and ultimately stop transmission. The communication review of
May 2019 concluded that in the highest risk areas for polio transmission the community engagement
strategy has been unable to build sustained community trust and ownership and reduce the number of
children missed during Supplemental Immunization Activities (SIAs).

To turn this situation around, the Pakistan Polio Programme’s 2020 National Emergency Action Plan
(NEAP) has introduced a number of interventions, innovations and modifications to respond to both
persistent programmatic challenges and new or unfolding epidemiological risks. One key strategic
change outlined in the 2020 NEAP is the refinement of the scope of areas implementing Community
Based Vaccination (CBV). This report details the objectives, methods, findings, conclusions and
recommendations from the CBV review commissioned by the National Emergency Operations Center
(NEOC) to support the CBV transition in 2020.

1 http://polioeradication.org/wp-content/uploads/2016/07/17th-IMB-report-20191115.pdf
2 http://polioeradication.org/wp-content/uploads/2016/07/pakistan-TAG-report-august-2019.pdf

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II. Introduction
II.1 Core reservoirs and geographic risk classification
Success in Pakistan largely depends on achieving and sustaining the highest possible vaccination
coverage in the polio core reservoirs. The programme defines a “core reservoir” as any clearly definable
contiguous geographic zone spanning an area that is not more than a division, or up to four closely
linked districts with proven persistent local WPV1 circulation for at least 18 months and repeated
history of reseeding virus outside the immediate transmission zone. Core reservoirs are areas that not
only sustain the WPV1 transmission but are also the primary in-country source of infection for all other
districts.

In order to enhance focus and guide area-specific approaches and efforts, the programme uses four
distinct risk tiers of districts: core reservoir districts (Tier 1), high-risk districts (Tier 2), vulnerable
districts (Tier 3) and low-risk districts (Tier 4). There are 11 Tier 1 (core reservoir) districts – Peshawar,
Khyber, Karachi (6), Quetta, Pishin and Killa Abdullah – with ~4 million children less than 5 years of age,
i.e. ~10% of the total target children in the country. There are 34 Tier 2 districts, 37 Tier 3 districts and
71 Tier 4 districts.

Within Tier 1 districts, the programme carried out further risk assessments at sub-district Union Council
(UC) level and have identified 40 UCs – categorized as Super High-Risk UCs (SHRUCs) - that represent the
greatest risk of polio transmission due to dense, underserved populations, increased vaccine hesitancy
and sub-optimal polio vaccination coverage. There are 8 SHRUCs in Karachi, 18 in Peshawar, and 14 in
Quetta block. The TAG recommended to scale up efforts with a ‘laser focus’ on these SHRUCs.

II.2 Supplemental immunization activities (SIAs)

Depending on the risk tier/categorization of the district/UC, house-to-house supplemental immunization
activities (SIAs) are implemented using one of three strategies: community-based vaccination (CBV),
mobile team (MT) strategy or special mobile team (SMT) strategy. As of February 2020, there were 595
UCs (8.2%) in the country implementing CBV strategy, there were 168 UCs (2.3%) implementing special
mobile team (SMT) strategy and 6,521 UCs (89.5%) implementing the mobile team (MT) strategy.

Harvard polling research in 2017 revealed a growing frustration with repeated and extended campaigns,
as nearly half of caregivers (48%) said there have been “too many” visits from vaccinators in the past
year. Under the 2020 NEAP, Pakistan’s SIA calendar ensures longer intervals (6-8 weeks) between
campaign cycles and shortened campaign duration to allow better preparation and implementation and
community acceptance. Campaign durations are five-day campaigns with two-day catch-up (5+2) in CBV
and SMT areas, and three-day campaigns with two-day catch-up (3+2) in MT areas. No extended catch-
up activities are to be conducted anywhere in the country.

2.2.1 Mobile Team and Special Mobile Team strategies

MT is the default strategy for house-to-house vaccination outside of the Tier 1 and select areas of Tier 2
districts. During NIDs, MT strategy covers about 90% of the target population. Under this strategy the
government, through the District Health Officer (DHO) and Union Council Medical Officer (UCMO),
recruits vaccinators for each SIA. Payment for staff is done through direct disbursement mechanism
(DDM), which is supported by WHO.

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In 2018, the SMT strategy was developed and implemented in limited targeted areas of northern and
southern Sindh and Islamabad that were plagued with persistent detection of positive environmental
samples. The hallmarks of the SMT strategy are expanded work schedules and intensified supervision.
SMT staff are recruited by a third party and managed by WHO for each SIA.

2.2.2 Community-Based Vaccination (CBV)

CBV has been the strategy of choice in the core reservoir districts (Tier 1) and in some areas of highest
concern for polio transmission in Tier 2 districts. Under this strategy, Community Health Workers
(CHWs) are hired from within their communities on a full-time basis. To facilitate access to households
and children, the foundation of CBV is that the CHWs are female. The core activities of this strategy are
the registration, vaccination and continuous tracking and vaccination of children missed during a SIA,
development of microplans and mobilization of communities.

II.3 Objectives of the CBV review

The size and scope of CBV today has increased the cost of the polio programme in Pakistan. While CBV
covers about 10% of the country’s <5 years target population, it accounts for more than 50% of the
programme’s operational costs. In addition, there are concerns about the programme’s capacity to
manage the current scale of CBV, as well as questions about the need for CBV in all UCs of Tier 1 and in
the selected Tier 2 districts where CBV is ongoing. In response to these concerns, the NEOC requested
the GPEI Hub to review the CBV strategy with the following objectives:

1. Assess the relevance of the project in each CBV district; review the historical justification of the
CBV programme and assess whether those justifications remain relevant today and/or whether
there are new whys and wherefores requiring the continued use of the CBV strategy
2. Assess whether the CBV strategy is good value for money for the GPEI programme and identify
the potential drawbacks to any changes in the scale and scope of CBV
3. Considering anticipated additional responsibilities, assess the current utilization of the
workforce including aspects such as registration of households and advice on the proper
utilization of the workforce
4. Provide specific district-by-district advice on scale and scope of CBV
5. Where changes are proposed, provide specific alternative proposal or combination of proposals
to mitigate against any potential drawback

III. Methodology
III.1 Setting and Design
Upon request from the Pakistan NEOC, the GPEI Hub in Amman, Jordan, assembled a 5-member CBV
Review Team made up of experienced polio staff from WHO, UNICEF, CDC and BMGF who are familiar
with the Pakistan polio programme. Initially, the Review Team planned to conduct both a desk review
and field visits but given the travel limitations imposed by the ongoing COVID-19 pandemic, all work was
done remotely. The original timeline for completion of the review was delayed from mid-April 2020 until
mid-May 2020 given the logistical constraints of working remotely.

The review was conducted for all areas implementing CBV strategy within Sindh, Balochistan and Khyber
Pakhtunkhwa (KP) provinces. Both qualitative and quantitative data collection methods were used to
address the objectives. Documents and data were collected for desk review from the NEOC through the
support of the assigned NEOC CBV Review Focal Point. Data was also collected from key polio staff at

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national, provincial, district and UC levels through questionnaires, interviews and focus group
discussions.

III.2 Desk review

Background documentation along with performance and cost data was collected from the NEOC (Annex
1) to define the context, and to assess the distribution of CBVs according to criteria, performance of the
CBV strategy in regards to SIA delivery and communications/community mobilization, and performance
and cost of CBV vis-à-vis the MT and SMT strategies.

III.3 Interviews, focus group discussions and online survey

3.3.1 Interviews and focus group discussions
A facilitator guide (Annex 2) was developed to facilitate the collection of qualitative data on the reasons
for initiating and expanding the CBV strategy, the criteria for UC selection, the relevance of the CBV
strategy when it was initiated and the relevance now, and pros and cons of CBV versus the MT and SMT
strategies.

The Review Team conducted key informant interviews via Zoom videoconferencing with the national
and two provincial Emergency Operations Centers’ Coordinators and had focus group discussions (FGDs)
with the national, three provincial CBV Task Teams and former WHO and UNICEF Team Leads/Deputy
Team Leads of the Pakistan programme. The interviews and FGDs were facilitated by 2-3 members of
the Review Team using the facilitator guide, which was sent out in advance. The discussions were
recorded, transcribed and analyzed.

3.3.2 Online survey

An online survey (Annex 3) was developed to collect responses from technical programme staff at the
national, provincial, district levels and in selected SHRUCs on the value of CBV versus the MT and SMT
strategies, if/how CBV improved various programme activities, the selection and management of CBV,
and the value of CBV for the improvement of communications/community engagement and routine
immunization. The questionnaire was converted into an ODK online data collection form, and a
hyperlink to the questionnaire was sent by email to the participants. Data was compiled automatically
by ODK Collect, then downloaded and analyzed.

3.3.3 Limitations
Flight suspension and travel bans did not allow the Review Team to travel to meet field level staff, but
effect of this was minimized through intense focus group discussions with national and provincial teams,
tele interviews of national and provincial coordinators as well as interviews of field level staff through a
standardized questionnaire using ODK. Despite our efforts, we were unable to interview provincial EOC
Coordinator of Sindh province as he was appointed during the review and swept up COVID-19 response
activities.

IV. Findings
IV.1 Desk Review
4.1.1 Geographic footprint of CBV
The CBV strategy was first captured in the 2015-2016 NEAP as a strategic intervention in the core
reservoir areas and was introduced at different times to different provinces, districts and UCs of
Pakistan from October 2014 to July 2018. CBV was first introduced in Karachi in October 2014 in parts of

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the highest risk UCs and expanded to all parts of the 8 SHRUCs in March 2015. In April 2015, an
additional 6 high-risk UCs were converted into CBV, and then an additional 85 UCs introduced CBV in
January 2016. CBV was introduced in Peshawar District, Khyber District and selected UCs of Bannu, Tank,
North Waziristan and South Waziristan in August 2016, and in Quetta, Pishin and Killa Abdullah Districts
in September 2016. The final expansion of the strategy was in the remaining 89 UCs of Karachi in July
2018, which created the current CBV footprint spanning 595 UCs in 27 districts in 3 provinces (Figure A,
Annex 4).

The plan under the 2020 NEAP is to reduce the CBV footprint by June 2020 to maximize CBV efficiency
and maintain focus on the core reservoir districts and the SHRUCs. This entails reducing from the current
595 CBV UCs in Tier 1 and Tier 2 districts to 374 UCs in Tier 1 districts only (Figure B, Annex 4). The plan
calls for transitioning 89 UCs in Karachi, five UCs of Peshawar Cantonment and 127 UCs of southern KP
to SMT strategy.

4.1.2 Recruitment and management

UNICEF is the lead partner for
overall management and
function of CBV strategy. Third-
party vendors (Sidat Hyder &
Morshed Associates (SHMA) in
Karachi and CHIP Training and
Consulting (CTC) in KP and
Balochistan Provinces)
contracted by UNICEF are
responsible for the
administrative management of
CBV workers inclusive of
recruitment, locality verification,
induction and refresher
trainings, deployment, timely
salary disbursement, staff
contract management,
performance evaluation and
travel logistics. All CBV staff are
fixed-term full-time staff to
ensure the availability of staff for
pre-, intra- and post-campaign
activities. Figure 2: Pre-transformation CBV staffing structure

At the UC and district levels in the current pre-transformation, management structure, a CBV “team” is
comprised of one CHW whose immediate supervisor is the Area Supervisor (AS), who is supervised by a
Union Council Communication Support Officer (UCCSO), who in turn is supervised by a District Health
Communication Support Officer (DHCSO) (Figure 2). While this management structure is seemingly clear
on paper, a management review conducted in 2019 by McKinsey & Company reported that the
“structure is described as “one team”, but in practice organogram has multiple parallel lines of authority
across partner organizations,” and “individual functions have some overlap in performance of roles
within TORs; actual activities conducted are also not fully consistent with TORs, resulting in further
overlap (with key challenge at UC-level) and lack of clear ownership.” In addition, the management

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review found that performance management of CBV staff was insufficient in terms of: a) performance
management philosophy is either missing (CTC only) or process-focused (SHMA); b) goal setting is
uniform and does not incorporate differing priorities between districts/UCs; c) formal feedback is
minimal and there is no culture for informal feedback; d) KPIs are unclearly defined and there are at
times too many KPIs (~40 KPIs for CTC field staff) to evaluate staff; and e) there is no well-defined link
between performance and financial or non-financial rewards.

Following the management review, the PEI structure at district and UC level is being revised. A main
component of the new structure will be that operations and communications will be separate streams of
work at UC level under one UC Polio Officer (UCPO) (Annex 5). At the district level, there will be a district
delivery and operation officer as well as a district communication officer to supervise operation and
communication respectively. For communications and community engagement at UC level, a new social
mobilisation cadre will be introduced in SHRUCs and some HRUCs, as follows:

• Tier 1 SHRUCs with CBV structure: House-to-house and Area Mobilisers

• Tier 1 HRUCS with CBV structure: Area Mobilisers
• Tier 1 & 2 HRUCs with SMT: Area Mobilisers as per need analysis
• Tier 3 & 4 UCs with SMT/MT: Area Mobilisers as per need analysis

Third parties will continue the recruitment, financial management and other administrative functions for
CHWs and their AS.

4.1.3 Accountability
Another key transformation coming from the management review is to establish performance
management systems across vendors that are similar and focus on having: a) a clear, output driven
performance management philosophy; b) differentiated goals and targets based on district/UC
priorities; c) regular developmental feedback (formal and informal) and detailed feedback sessions
around appraisals; d) well-defined 3-5 KPIs that are easy to track; and e) a clear policy around
performance and rewards/consequences that is consistently applied.

4.1.4 HR Analysis and workload distribution

Currently, there are 19 provincial level staff exclusively working on the CBV strategy (8 in KP, 7 in
Balochistan and 4 in Karachi). Also, there are 10 CBV managers, 4 training coordinators and 6 data
managers at provincial level. At the district level there are 233 staff exclusively working on CBV (123 in
Karachi, 58 and 52 for Quetta and Peshawar, respectively). The cadres at the district level include
District Health Communication Support Officer (DHCSO), master trainer and data support officer.

Currently there are 19,484 CHWs under CBV: 11,648 (60%) in Karachi covering 2,230,723 target children;
4740 CHWs in KP covering 1,240,291 target children; and 3096 CHWs in Quetta Block covering 688,658
target children. Hence, CHWs are targeting ~4.1 million children every SIA, which is about 10% of the
total target population for the country. The average per day target for each CHW is 37 children per day
for Quetta Block and is around 40 children per day for KP and Karachi districts.

The proportion of CHWs that are female is 86% overall in CBV areas but varies widely by tehsils/UCs. In
Karachi, KP and Quetta Block the proportion female is 100%, 49% and 83%, respectively. In KP, outside
of Peshawar, Bannu Tehsil and Tank Tehsil, CHWs are predominantly male: in Khyber District, only 4/51
UCs have female CHWs; in North Waziristan 5/23 UCs have female CHWs; and in South Waziristan 0/78
UCs have female CHWs. In Quetta Block, the majority of CHWs are female with the exception of the

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Deobandi, Gulistan and Killa Abdullah tehsils of Killa Abdullah District where only 15%, 30% and 37% of
the CHWs are female.

There are currently 4685 AS deployed in CBV areas. Karachi has the largest number of AS (2554, 55%),
followed by KP (1328, 28%) and Quetta Block (803, 17%). AS supervise 4 to 5 CHWs on average, while
UCCSOs supervise 5 to 6 AS on average. The distribution of staff and workload for CBV are detailed in
Annex 6. The majority of AS are male in Quetta Block (70%) and KP (54%). However, in Karachi most
(98%) of the AS are female. UCCSOs are predominantly male.

4.1.5 CBV and SIA performance

4.1.5.1 Epidemiology

Figure 3: WPV1 cases in CBV areas, 2015-2020

As seen with the country overall, from 2015-2020 there was persistent WPV1 transmission in the CBV
areas, with a trend of decreasing number cases until the surge of cases in 2019 (Figure 3). Across this
same time period, there was a trend of decreasing proportion of WPV1 cases in CBV areas versus non-
CBV areas, where 80% of WPV1 cases in 2015 and 11% of WPV1 cases in 2020 were from areas that are
part of the current CBV footprint (Figure 4).

Figure 4: Proportion of WPV1 cases in CBV vs. non-CBV areas, 2015-2020

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Karachi: From 2016-2020, the epi-curve of WPV1 cases and environmental surveillance positive (ES+)
isolates in Karachi indicates persistent transmission with the exception of 2016 when there were
extended periods without cases or ES+ isolates (Figure 5). From mid-2017 there was significant increase
in the proportion of positive environmental samples collected from Karachi. There is also relative
increase in number of cases in 2019 reported from different parts of Karachi. Genetic sequencing of
WPV1 for 2017-2020 reflects that Karachi continues to serve as a core reservoir with continuation of
indigenous multiple lineages of transmission, with spread to parts of northern Sindh (Jacobabad,
Kambar, Larkana and Sukkur districts) and to parts of southern Punjab.

Figure 5: Proportion of WPV1 cases in Tier 1 CBV areas, 2016-2020

Peshawar-Khyber Block: Peshawar and Khyber districts reported only 2 WPV1 cases during 2017-2020,
but low-level transmission of WPV1 throughout this period is indicated by isolation from ES (Figure 5).
However, while there is an outbreak of cVDPV2 in Peshawar-Khyber, there has been no WPV1 isolated
from ES since November 2019 and no WPV1 case since February 2016 in this block. Genetic sequencing
from 2018-19 shows spread of WPV1 from Peshawar to adjacent areas of KP (Khyber, Bannu, Torghar,
Shangla, Lakki Marwat, and North and South Waziristan districts), southern Punjab (DG Khan and Multan
districts) and Karachi.

Quetta Block (Quetta, Pishin and Killa Abdullah districts): The epi-curve of WPV1 in Quetta Block for
2018-2020 indicates persistent transmission with a gradual increase in the proportion of ES+ samples
collected in 2019-2020 (Figure 5). There is also relative increase in number of cases in 2019, mostly
reported from Killa Abdullah District. Genetic sequencing for 2017-2020 indicate multiple introductions
with subsequent established and ongoing local transmission. Quetta block continues as a core reservoir
with evidence of spread to adjacent areas (Mastung, Khuzdar) and to Karachi.

South KP Tier 2 Districts (Bannu, Tank, North and South Waziristan districts): The outbreak of WPV1 in
South KP, particularly in the 4 Tier 2 districts and their adjacent districts, started in 2018 and continues
in 2020 (data not shown). These districts reported 34 cases of WPV1 in 2019, which is 23% of the total
146 cases reported in 2019 from the country.

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4.1.5.2 SIA performance by vaccination strategy, as per admin coverage, ICM & PCM results
Between January 2018 to February 2020 Pakistan conducted 8 rounds of national immunization days
(NIDs) campaigns that covered all UCs in the country regardless of tier classification or vaccination
strategy. Looking at administrative data at the national level, coverage was consistently lower in areas
implementing CBV in comparison to areas implementing MT and SMT (Figure 6). In addition, the
proportion of children missed was consistently higher in the CBV areas compared to the SMT and MT
areas. The average still missed children proportion for CBV UCs was 4.9% (range: 3.4% - 7.8%) while the
average for SMT UCs 1.8% (range: 0.5% - 4.0%) and for MT UCs it was an average of 0.4% (range: 0.2% -
0.6%). The trend was similar when disaggregated by province, and the trend was similar for the
proportion of missed children against recorded missed children.

In terms of addressing refusals, looking at the proportion of still refusals aggregated at the national level
there was consistently greater proportions of still refusals in CBV areas compared to SMT and MT areas.
At provincial level, Karachi reported the highest number of refusals: KP and Balochistan consistently
reported less than 1% still refusal, while on average Karachi reported more than 3% still refusal.

Aggregated at the national level,

the same day coverage, which
measures the daily performance
of the teams, was similar across
vaccination strategies: on average
48% for CBV, 46% for MT and 49%
for SMT. Disaggregating by
province, same day coverage was
consistently greater in Sindh,
lower in Balochistan and in-
between in KP. CBV in Sindh and
KP had consistently greater same
day coverage compared to the
MT, while in Balochistan CBV had
consistently lower same day
coverage compared to MT. Figure 6: Admin Coverage for NIDs by vaccination strategy

In terms of intra-campaign monitoring (ICM) clusters coverage, the average ICM coverage for the 8 NIDs
for MT areas was 91% (range: 89% - 92%), which was similar for SMT (91%, range: 86% - 93%). On the
other hand, the average ICM clusters coverage for CBV areas was 85% (range: 81% - 88%). There were
no significant ICM coverage differences across provinces. For the 5 NIDs with post campaign monitoring
(PCM) results, there were no significant differences across vaccination strategies at national or
provincial levels.

Overall in Tier 1 districts, in 2015-2016 most children missed vaccination because houses were missed,
teams did not visit, parents refused to vaccinate, or children were not available at the time of team’s
visit. From 2017-19, the proportion of “missed houses” or “no team visit” reduced significantly. In 2018
and 2019, there was also a substantial proportion of missed children for whom parents reported
vaccinated but without evidence of finger mark. In terms of lot quality assurance sampling (LQAS), in

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2018, CBV and MT areas had comparable LQAS lot pass rates, while SMT areas had consistently lower
LQAS lots pass rate. In 2019, LQAS pass rates were similar across strategies.

4.1.5.3 SIA performance across time in CBV areas

In Quetta District from March 2015 to Dec 2018, the trend of the recorded and still missed children was
flat in the period before CBV was introduced. After CBV introduction there was significant increase for
both recorded and still missed
children that continued to increase
throughout this period. (Figure 7).
Following the introduction of the CBV
strategy in Quetta, we observe an
increase in the proportion of children
remaining as refusals both against
the target and against the recorded
refusals. However, the overall
administrative coverage and same
day coverage proportions were not
significantly changed by the
introduction of CBV (Figure 8). In
terms of LQAS, of the 9 SIAs held in
2015, an average of 29% (range: 0-
78%) of lots passed in Quetta Block.
Figure 7: Still missed children, Quetta, 2015-2018
In 2016 and 2017 the proportion of
passed lots increased significantly to
an average of 84% (range: 77-89%) and 81% (range: 77-98%). Marginal increases in proportion of lots
passed occurred in 2018 and 2019 to on average, 85% (range: 77-98%) and 89% (range: 84-92%).

In Peshawar District from January 2015 to April 2018 there were 8 SIAs before and 8 SIAs after CBV
introduction. The proportion of missed children decreased sharply in 2015, held steady in 2016,
increased in late 2016 after CBV introduction and remained constant afterwards (Figure 9). The
proportion of children remaining as refusals both against the target and against the recorded refusals
increased, while overall administrative
coverage and same day coverage were
not significantly changed by the
introduction of CBV. For Peshawar and
Khyber districts combined, LQAS
results were more stable and
consistent compared to other Tier 1
districts (Annex 7). The proportion of
passed lots increased from 88%
(range: 79-97%) in 2016 to 94% (range:
86-98%) and 94% (range 91-100%) in
2017 and 2018, respectively. The
proportion of passed lots declined in
2019 to 84% (range 75-93%). Figure 8: Overall and same day admin coverage, Quetta, 2015-2018

In Karachi, at the beginning of 2014,

SIA coverage from administrative data Figure 9: Still missed children, Peshawar, 2015-2018

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was 54%. After CBV introduction,

administrative coverage increased
and peaked in the first quarter of
2015. Subsequently, from the first
SIA in 2015 to SIA in February 2020
both administrative coverage and
same day coverage stayed relatively
constant at an average of 100% and
50%, respectively (Figure 10). On
the other hand, during the same
period the number of recorded
missed and remaining still missed
children increased, and the
proportion of vaccine refusal
children among the targeted Figure 10: Overall and same day admin coverage, Karachi, 2014-2020
steadily increased, doubling in 2018
compared to the previous years
(Figure 11). Following the Peshawar
incident in April 2019, the proportion
of refusals skyrocketed, but returned
to the 2018 level in subsequent SIAs.
In terms of LQAS (Annex 7), the
quality of SIAs remains inconsistent
and mostly sub-optimal in Karachi.
The proportion of passed lots, on
average, in 2016 and 2017 were 74%
(range: 56-96%) and 80% (range: 67-
88%), respectively, but then declined
significantly to an average of 75%
(range 53-92%) and 55% (range: 35-
80%) lots passed in 2018 and 2019. Figure 11: Still refusals (targeted & recorded), Karachi, 2014-2020
None of the SIAs during 2017-2019
achieved the target set in NEAP of
90% lots passed.

IV.2 CBV and community engagement

There have been two recent reviews (May 2018 and May 2019) of the Communication for Eradication
(C4E) strategy that shed some light on the context, challenges and results in terms of missed children
and refusals in CBV areas. The May 2018 review found that “missed and still missed children rates have
plateaued since July 2017 in CBV areas, suggesting the programme may be missing the same children
round after round, or that caregivers are not committed to vaccination during every round.” The review
went on to report that “these children may represent soft refusals, vulnerable to becoming active
resistors with the right spark of misinformation, normative shifts or mistreatment by the programme.”

The communication review of May 2019 surfaced two critical issues which have limited the ability of the
CBV strategy to deliver on its original goal of building community trust and steadily decrease missed
children. The intense SIA schedule has not allowed for sufficient time amongst CHWs to carry out
community engagement activities, and at the same time their planned communications functions have

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been largely consumed by operational responsibilities. The 2019 C4E review further concluded that
management and coordination challenges persisted: “Existing communication resources COMNet, CBV,
CSO, RSP can be better coordinated and supervised and potentially concentrated in the highest risk
areas to meet emerging polio challenges.”

IV.3 Cost analysis

IV.3.1 Cost of CBV vs MT/SMT
The GPEI-approved budget (USD$46 million) and costing details of CBV for 2020 were compared to what
the estimated costs would be for implementing the MT or SMT strategies in the 595 CBV UCs. Generally,
all three vaccination strategies have the same fundamental components: a similar number of staff at a
comparable daily salary (USD$3.50-5.50/day); modest campaign and operational costs; a provision of
supply kits to a similar number of staff; and overhead costs. Using costing data provided by UNICEF and
WHO, the annual cost for a UC to implement CBV is, on average, 4-6x what it would cost to implement
the MT or SMT strategies. The primary drivers of the greater cost of CBV is the full-time/year-round
retention of staff, and the 10-15% overhead cost paid to the third party for HR management (Figure 12).

Figure 12: Estimated UC Programme Cost Components, by vaccination strategy for the 595 CBV UCs

IV.3.2 Financial impact of transitioning UCs from CBV to MT or SMT

As per the 2020 NEAP, 221 UCs will transition from CBV to SMT. This transition is projected to save
~$11M/year (Figure 13), primarily as a result of having staff in place for just 60-72 days per year (10-12
days for each of 6 campaigns per year, using 2020 NEAP as the guide for the number of campaigns).

Figure 13: Estimated Cost Savings for transitioning 221 UCs from CBV to MT or SMT

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Noteworthy is that the CBV cost per average cost per person is ~20% higher for the group of 221 UCs
that are transitioning out of CBV compared to the UCs that will retain CBV. Within the UCs transitioning
out of the CBV strategy, the cost per target person is 49% greater for SMT strategy ($2.20 per person,
per year) compared to MT strategy ($1.48 per person, per year), primarily due to the 10- or 12-day pay
period per SIA for SMT versus the 5-day pay period per SIA for MT. On a pure labor cost basis, the SMT
workers provide better value for money in terms of number of days with full staffing to execute
campaign objectives (Figure 14).

* assumes CBV workers work on average 6 days/week

Figure 14: Average Daily Cost per Worker, by vaccination strategy

For the 374 UCs continuing as CBV as per the 2020 NEAP, the polio programme will pay ~$27M in
additional costs at the UC level to retain the CBV strategy in these areas, in lieu of switching to the lower
cost MT or SMT strategies that requires only very targeted staffing periods around campaigns (Figure
15).

Figure 15: Estimated Premium to Retain CBV in 374 UCs

IV.3.3 Case study: Khyber District

Khyber District in KP has struggled to retain female health workers to implement CBV. From a cost
perspective, Khyber District would save ~2.1M per year by transitioning to SMT (Figure 16). Khyber
District is projected to be able to implement either the SMT or MT strategy at a cost per person that is
25-30% less than the national average, while the cost to implement CBV comes at a 4% higher cost per
person in the target population than the national average.

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Figure 16: Estimated Cost by vaccination strategy, Khyber District

IV.4 Online survey

An online survey was administered to the technical staff at the national, provincial, district and UC
levels. There was high response rate across the duty levels and across the provinces, with the exception
of KP province where only 35% of the targeted UC staff participated. In total there were 510 participants
in this survey, the majority of whom were UC level staff (60%) followed by district (34%), province (5%)
and national (2%) level staff (Figure 17).

Figure 17: Distribution of survey respondents by administrative level

When asked what value the CBV added to the Pakistan polio programme in terms of performance, 67%
of participants responded that there was ‘much improvement’ in performance with the introduction of
the CBV, 24% responded that there was ‘minimal improvement’, while the remaining participants
responded there was ‘no difference’ (3%) or that performance ‘deteriorated’ (6%) with CBV. Nobody
from the national team said there was ‘no change’ or that performance ‘deteriorated’ after CBV
introduction. UC staff in Sindh province had the lowest proportion of staff (55%) responding that there
was ‘much improvement.’ The lowest favorability to the improvement in performance was from Malir
(district staff), Baldia (UC staff) and Site (UC staff) in Sindh province at 33%, 33% and 20%, respectively.
In Balochistan, district staff from Pishin had both lowest ‘much improvement’ response at 45% and
highest ‘performance got worse’ at 27%. In KP, district staff from Tank were divided 50% / 50% between
‘much improvement’ and performance ‘got worse’, with nothing in between.

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When we asked how much did the CBV strategy improve the microplanning process, overall 44% of the
participants responded that there was ‘much improvement’, 34% responded that there was ‘moderate
improvement’, 15% responded that there was ‘minimal improvement’, 6% responded that there was ‘no
improvement’ and 1% responded that the quality of the microplanning ‘deteriorated’. The most
unfavorable responses come from provincial and UC level staff from Sindh. Similarly, when asked about
CBV’s impact on workload rationalization, overall 37% of the participants responded that there was
‘much improvement’, 40% responded ‘moderate improvement’, 19% responded ‘minimal improvement’
and 4% said ‘no improvement’. All national level participants responded either ‘much improvement’ or
‘moderate improvement’. Most unfavorable responses came from provincial staff from Sindh and
Balochistan.

When asked about the impact of the CBV strategy on community trust in areas where it is being
implemented, overall 31% of the participants responded that there was ‘very high improvement’ in the
community trust, 42% responded ‘moderate improvement’, 20% ‘minimal improvement’, 5% ‘no
change’ and 2% responded that community trust had ‘deteriorated’. All national staff said there was
either ‘high improvement’ or ‘moderate improvement’. The majority (63%) of Balochistan provincial
staff responded that community trust had ‘deteriorated’ with the introduction of CBV. All Sindh
provincial staff either said there was ‘minimal improvement’ or ‘moderate improvement’, while 90% of
KP provincial staff said there was ‘moderate improvement (Figure 18). There were mixed responses
from both the district and UC staff in KP. Tank District staff gave the most unfavorable responses with
50% responding that community trust had “deteriorated’.

Figure 18: Did introduction of CBV improve community trust?

When asked about social mobilization activities, overall 42% of participants responded that there was
‘high improvement’ of social mobilization with the introduction of CBV, while 35% responded ‘moderate
improvement’, 15% ‘minimal improvement’, 6% ‘no change’ and 2% that social mobilization had
‘deteriorated’. All national staff responded that there was ‘moderate improvement’. Most unfavorable
responses were received from the Balochistan provincial team with only 13% reporting ‘high
improvement’, 25% ‘minimal improvement’, 38% ‘no change’ and 25% said that social mobilization had
‘deteriorated’ under CBV.

When questioned about improvements in the missed children coverage, overall, 39% of the participants
said there was very improvement, 38% said there was moderate improvement, 19% said there was
minimal improvement, 3% said there was no change and the remaining 1% said there was deterioration.
When asked about how the CBV programme was managed compared to the MT and SMT strategies,

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overall, 69% said the CBV strategy is managed better than the other strategies, 22% said it is managed
just like the other strategies and 8% said it is poorly managed.

When asked whether the repeat micro-census exercise was necessary, 87% of the respondents said
“yes” and the remaining 13% said “no”. However, only 33% of the national staff responded with “yes” to
this question. Interestingly, the positive response increased as you go to the lower duty levels with more
staff at the national saying it is not necessary compared to the provinces, more at the provinces saying it
is not necessary compared to the districts and majority at the UC level saying it is necessary compared
to the district level staff (Figure 19).

Figure 19: Is it necessary to have repeated micro-census?

The view on the repeated updating of the microplans was similar to the repeated micro-census. When
asked about whether the CHWs had enough time to carry out inter-personal communication (IPC) or
community engagement (CE), 67% of the participants said “yes”. However, the majority of the senior
technical staff at the national (56%) and provincial (Sindh=83%, KPK=70% and Balochistan=38%) level
responded “no” to this question. With all the district staff at Layari and Liaqatabad in Karachi saying the
CHWs did not have enough time for IPC and CE. On the question of whether the CHWs were receiving
appropriate training and supervision, majority (86%) said “yes”. However, 63% of Balochistan provincial
staff said “no”. When we asked about whether it was always easy to find the right CHWs and CHW
supervisors (local woman who belong and speak the language of the communities they work for)
majority of the national (67%), provincial (71%) and district (56%) said it was not easy to find
appropriate CHWs and CHW supervisors where they are needed.

IV.5 Focus Group Discussion (FGDs)

The following is a summary of relevance and advantages/disadvantages of CBV as per the four FDGs and
interviews of the national and provincial EOC coordinators.

IV.5.1 Relevance of the CBV strategy

• CBV was introduced and expanded to overcome some major barriers causing hindrance in the
implementation and achievement of optimal quality of SIAs in the core reservoir districts. These
hindrances and barriers included:
o Serious insecurity situation requiring huge presence to Law Enforcement Agencies (LEAs)
to protect polio workers;
o Dominance of paramedics, leading to repeated boycotts and exploitation;

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o Teams going on strike from time to time and high turnover rate if their work
performance was questioned;
o Hiring of HR violating the requisite criteria;
o Hiring majority males who can’t enter inside households;
o Hiring untrained school children;
o Ghost teams; and
o Inflated targets and coverage over-reporting.
• With introduction of a workforce of female CHWs through CBV strategy, these challenges are
significantly reduced or no longer persist.
• CBV has additional advantages (see next section) including better access, better quality of data,
micro-plans and accountability.
• CBV largely succeeded in breaking through the firmly held belief that the programme would
never get women to work in most of the Tier 1 areas. CBV also stabilized the workforce (moved
away from dependence on government, which was negatively impacting the programme
because of HR shortages and frequent turnover. From this perspective, it seems more about HR
processes than CBV as such…another strategy that stabilizes the workforce and places the same
effort in the hiring of females could resolve the same HR issues.

IV.5.2 Critical Functions, advantages and disadvantages of CBV strategy

Functions Advantages Disadvantages

Team composition and Access
Registration and microplanning
Reporting and recovering of
missed children
Supervision
Data and funds flow
Well trained and experienced
workforce of local females, speaks
local language and can enter inside
houses to ensure vaccination of all
eligible children including newborns
All houses and children in an
assigned area are registered.
Accurate data of every eligible child
in each household is available.
CHWs know each family and
maintain good relationship.
Registration of children is validated
before each round and microplans
are updated
Generally, very good reporting of
missed children due to any reason.
Regular follow up visits to
vaccinate not available children
and convince refusal families
Strong supervisory structure of
Area supervisor and UC level
supervisors
Daily reports of coverage and
missed children by reasons. Better
quality data with timely flow from
field to district to provincial level
In areas where CHWs are mostly
male have poor or no access inside
houses
Reports of monitors and field
investigations shows that a sizable
percentage (3 – 9 %) of eligible,
particularly the very young children
are either un-registered or missed
during vaccination campaigns. It
does vary from area to area--a
problem that cannot be ignored.
Long-standing relationship of CHWs
with family/community leads to
non-reporting of refusals, resorting
to fake finger marking (FFM) to
cover up. Extent of FFM varies but
difficult to measure.
Most of the supervisors are male
which in some cases has shown
evidence of exploitation,
harassment and abuse of authority
to cover up issues

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Communication for Eradication
(C4E)
Accountability and fund flow
Other services and functions
Within CBV strategy, there is Frequent SIAs, multiple door
network of community mobilizers knocks, and anti vax propaganda
with regular awareness sessions led to breach in community trust
and use of influencers refusals
Regular employees of third-party Cost per child is significantly higher
vendor; independent and than other strategies. In some
transparent process of selection, cases of tribal influence does
local political interference is impact transparency, impartiality
minimal. Performance monitored, of recruitment process. Also, some
and actions are taken. Regular and instances of recruitment of close
direct payment mechanism relatives or friends of areas or UC
supervisors observed in few areas
leading to under reporting of
issues.
Reporting of Routine “zero dose”
children and referral to fixed site
for RI vaccination. Assist other
antigen vaccination campaigns
including Measles, TCV and
multiantigen SIAs
During COVID-19 response, they
were engaged for identification &
listing of poor, destitute families for
financial / food item support
They are now engaged in Risk
Communication & community
engagement; raising awareness on
COVID 19 by visiting households
and distribution of IEC material;
They can be engaged for various
surveys/screening of malnourished
children, etc.

IV.6 Community trust and demand

As identified during C4E strategy review in 2019, and partly supported by the qualitative interviews of
this review, the original purpose of the CBV strategy when it comes to in-between campaign community
engagement functions and accountabilities have been consumed by many competing operational
priorities. This has resulted in a ‘community vacuum’ where the broader community ownership and
support of the programme was not being systematically addressed while the assumptions were that
CHWs were doing it. Another aspect of the reduced capacity of the CHWs to build broader community
trust through key influencer engagement was the limited time the programme had in-between
campaigns to carry out these trust building activities. As a result, and as indicated by the data, CBV
strategy has only been partly successful in specific areas (e.g. Peshawar).

NEAP 2020 and the revised C4E strategy are proposing a series of strategic improvements to the overall
communication strategy and how CBV strategy in particular is being strengthened by introducing a
dedicated social mobilisation structure at the doorstep and in the community at large (Annex 5). Directly
linked to this is the shift that has been introduced in the SIA schedule and a more strategic order of key
communication related processes to make them more strategic and relevant (Annex 8).

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At the same time the programme is addressing the disconnect between community level work and the
efforts carried out through traditional and social media channels to ensure a better integration.
A key strategic shift is also being implemented at the doorstep where CHWs have been trained and
equipped with communication tools to allow them address key family practices (KFCPs), health topics
beyond polio, to increase the value of their visit from the caregiver’s perspective and hence increase
acceptance and trust that will hopefully lead to more vaccine acceptance during multiple campaigns.
The planned strategic improvements in the overall C4E strategy, which will have direct and indirect
impact on the success of the CBV strategy, include:

• Additional cadre of area social mobilisers and house-to-house mobilisers in SHRUCs;

• Alliances & coalitions (traditional, religious and medical) at community level to create an
enabling environment catering for success at the doorstep. This would also entail a closer look
at the overall religious influencer strategy to ensure it is fully integrated in the overall C4E
strategy and fully utilized to create community support and demand for vaccination;
• Integration between PMI/social & traditional media and C4E to ensure integrated and
coordinated use of local influencers and consistent messaging in CBV and non-CBV areas
• Positioning Sehat Tahaffuz Call Center as immediate support mechanism for house-to-house
mobilisation;
• Broader messaging package at the doorstep for CHWs to allow them to position themselves
within the broader community health sector;
• Building more time and capacity in-between campaigns for sustained community engagement
with a dedicated workforce in SHRUCs by increasing time between SIAs; and
• Critical focus on Pashtun population with the engagement of Pashtun influencers in community
level work as well as in social media and ensuring Pashtun speaking social mobilisers are
engaged locally.

V. Discussion and Conclusions

On relevance:
Looking historically, a review of CBV in May 2016 (before the expansion of the strategy expanded to all
Tier 1 districts and parts of Tier 2 districts) concluded that “…data/site visits clearly shows that the CBV
is the best available model to identify and significantly reduce missed children in high risk areas” and
that “CBV has successfully gained access to areas and children previously inaccessible to the polio
programme and has rapidly increased the quality of polio vaccination services where consistent quality
of operations were problematic.” The direct community engagement inherent to the CBV strategy has
been instrumental in improving the security of frontline workers (FLWs) and has enabled the transition
from multi-phased to single-phased SIAs.

CBV has largely succeeded in breaking through the firmly held belief that the programme would never
get women to work in most of the Tier 1 areas. The exceptions to this are found in three tehsils (Killa
Abdullah, Deobandi and Gulistan) of Killa Abdullah District and 47/51 UCs of Khyber District, where the
programme hasn’t been able to hire females, mainly due to understandable cultural reasons. As the
primary intent on having female CHWs in these areas was not met – and may never be met – it is clearly
necessary to shift vaccination strategy. It is important to note, however, that while most of the CHWs
are females with the exceptions noted, their immediate supervisors (Area Supervisors) are
predominantly male in Quetta Block and in CBV districts of KP province.

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CBV also stabilized the workforce (moved away from dependence on government which was negatively
impacting the programme because of HR shortages and frequent turnover. From this perspective, it
seems more about HR processes than CBV as such – a different vaccination strategy that stabilizes the
workforce and places the same effort in the hiring of females could possibly resolve the same HR issues.

CBV continues to play a role in supporting activities beyond SIAs. Achieving and maintaining high
essential immunization coverage in the CBV areas, particularly in pockets of persistently low coverage
and underserved populations, is critical to stopping WPV1 transmission in the core reservoir districts. All
districts and areas where CBV is implemented have weak immunization systems with large numbers of
under-immunized or unimmunized children. In support of essential immunization, CHWs record
newborn and under-immunized or unimmunized children and prepare lists shared with the respective
EPI team, although the use of this data and action from EPI teams remains sub-optimal. In addition,
FLWs in CBV areas have played an important role in planning and implementation of measles, IPV and
multi-antigen SIAs in their respective areas.

Beyond essential immunization, the TAG recommended integrated service delivery ISD (WASH,
Nutrition) for the 40 SHRUCs – areas with the most marginalized communities lacking basic needs. This
is an important intervention towards community engagement and an important area of work for the
involvement of the CHWs.

It is also important to mention that CBV staff are currently playing an important role in response to the
COVID-19 pandemic through identification & listing of poor, destitute families for financial / food item
support, and risk communication and community education and engagement.

Considering these points and the findings from FGDs and interviews, the Review Team concludes that
apart from the exceptions detailed in the recommendations on the scale of the CBV strategy below, the
CBV strategy is still relevant.

On performance:
While the annual number of cases in CBV areas was on a downward trend until 2019, ES results have
confirmed ongoing transmission (albeit with seasonal highs and lows) – with CBV areas largely acting as
the source of virus for other parts of Pakistan – throughout the period of CBV implementation. From the
available SIA monitoring data, for many of the CBV areas it appears that the CBV strategy hasn’t
overcome the existing challenges to achieving high levels of performance during SIAs that would lead to
interrupting transmission.

CBV underperformance can be attributed to several factors including sub-optimal government

leadership, management and accountability, partner staff coordination at field level and community
trust and demand. The CBV strategy needs to be implemented in an environment that enables its
implementation by addressing these inhibiting factors. Government leadership and oversight and
programme management are discussed below. In addition to these factors, the CBV strategy cannot be
successful if it operates in a ‘community vacuum’ – the overall community engagement strategy of the
programme within the C4E strategy should be creating an enabling environment – community trust and
ownership – that directly supports the CBV strategy whereby CHWs would play a critical role of
vaccinating every child every time at the doorstep.

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On value for money:

Regardless of performance, the programme can’t maintain components that it simply cannot afford. The
annual cost for a UC to operate a CBV programme is, on average, 4-6x the cost to implement a SMT or
MT programme in that same area. However, analysis of critical functions, advantages and
disadvantages, CBV’s potential role in essential immunization and integrated services for underserved
communities, the Review Team feels that CBV strategy is good value for money provided it is
implemented in selected areas.

The CBV programme was launched with high expectations that by relying on local women in the
community for outreach and vaccination, refusal rates would materially decline, addressing a critical
leverage point for the programme. As such, GPEI approved a $46M plan in 2020 for CBV implementation
in Pakistan, which constitutes ~20% of GPEI’s annual budget for Pakistan. As the cost analysis
demonstrates, the CBV programme is substantially more expensive than a S/MT strategy and therefore
should only be retained in areas where refusal rates are highly elastic based on who is knocking at the
door, either due to the trust extended to a local woman (vs. a hired, often male, vaccinator who is not
from that community) or due to the intangible benefits of community integration with the polio
programme, including the goodwill generated by creating local jobs.

Regarding Khyber District specifically, in addition to CBV not being a strong cultural fit as mentioned
above in the section on CBV relevance, CBV is also not a strong financial fit for the district based on the
relative efficiencies within the district that are reflected in how the various strategies are each projected
to be implemented.

On leadership, oversight and management:

Experience in several districts of the country and the ongoing COVID-19 response clearly underscores
the capacity and ability of national and provincial governments to effectively respond to national public
health emergencies through collaboration but under national leadership.

As per the NEAP and CBV policy, CBV is a component of the government’s polio programme that is
outsourced to an implementing partner for administrative management (transparent hiring,
disbursement of salaries, insurance management, data and record keeping, etc.), but for programme
performance and accountability it is under the government’s purview, as is all aspects of the polio
programme. One take-away from the FGDs is that CBV management teams and local managers were
over-possessive to an extent that they discouraged engagement of the government. As a result, there
has been a feeling that the polio programme in CBV areas is “one partner’s programme,” undermining
government ownership and accountability as well as the “one team” approach. At the field level,
leadership and oversight fall under the district administration led by Deputy Commissioners. While the
leadership of district administration (DCs / ACs) and engagement of health department staff in SIAs is
critical, their leadership and oversight vary from district to district and generally remain sub-optimal.

CBV is an extensive initiative with thousands of staffs and workers, requiring a very robust management
support system. A common theme from the FGDs and interviews was that management of CBV has been
sub-optimal, particularly as it expanded to its current footprint – with the passage of time, some degree
of complacency and gaps in CBV management at various levels have presented major barriers in
achieving optimal results. Most CBV managerial staff, particularly at district and UC levels, have more
technical backgrounds with limited managerial experience, skills and abilities particularly ability to
identify problems and address them effectively.

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With an average daily target of 37-40 children for each CHW, the average workload overall is rational
and manageable for CHWs and their supervisors. The Review Team did not have the data to rule out
that there are specific areas or specific staff that would benefit from further workload rationalization.
However, regardless of the rational workload, the morale of FLWs is at risk: there were perhaps
unrealistic expectations for FLWs to conduct high-quality campaigns whilst maintaining community and
parental engagement; some FLWs are fatigued due to multiple rounds and community behavior; and
after years of efforts with sometimes little or no change in epidemiology, some FLWs have started
believing that eradication may not be possible.

The ongoing Transformation initiative has identified areas in the CBV management that need to be
addressed urgently and certain actions were proposed upon implementation of which the CBV areas are
expected to have a well-defined management and operation structures at national, provincial, district
and UC levels. In addition, there is an initiative ongoing to reduce the amount of data collected through
the CBV strategy and improve the use of this data for planning and monitoring.

On risks and challenges associated with CBV transition:

A shift from CBV to an alternate strategy will not be free of risks and operational, managerial and
political challenges. CHWs and their area supervisors working in CBV areas are employed through a
third-party contract and are paid a fixed amount on monthly basis as salary. Those who are laid off or
who are transitioned to part-time and therefore lower-paying SMT or MT positions may react by
spreading negative messages and seeding refusals or campaign boycotts by communities, and possibly
providing fodder for anti-vaccination groups. In some areas, local political sensitivities may compound
and further complicate the situation, as provincial and local political leadership may pressurize the
programme to take back the decision.

CBV transition may also affect FLWs in areas where CBV strategy is retained. On one hand, their morale
may go down as they may be fearful of job security, while on the other hand it may have a positive
affect on the programme as FLWs recognize that it is no longer “business as usual” and they need to
perform better. In transitioning areas, new workers brought in will not be as familiar with the
programme, possibly negatively affecting quality of campaigns.

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VI. Recommendations
VI.1 Recommendations on the Scale of the CBV strategy

i. Tier 1 Districts
• Karachi:
- The Review Team endorses the 2020 NEAP plan to exclude 89 UCs in Karachi from CBV
strategy. Timeline: this should be done by June 2020
- In addition to the above 89 UCs, the Review Team recommends that in next 12 months CBV
strategy should be limited to the 34 highest risk UCs (8 SHRUCs and 26 VHRUCs) of Karachi.
Timeline: this should be done by June 2021

• Peshawar District: The Review Team endorses the 2020 NEAP plan to exclude 5 UCs that include
Cantonment areas of Peshawar from CBV strategy. Timeline: this should be done by June 2020

• Khyber District: The Review Team recommends that the CBV strategy should be excluded from
the entire Khyber District, as CBV is largely implemented through male teams. Timeline: this
should be done preferably by December 2020 but not later than June 2021

• Quetta Block: The Review Team recommends that the CBV strategy should be excluded from the
3 tehsils of Killa Abdullah District (Killa Abdullah, Deobandi and Gulistan) where CBV is largely
implemented through male workers. Timeline: this should be done preferably by December
2020 but not later than June 2021

ii. Tier 2 Districts

• Bannu, Tank, North Waziristan and South Waziristan districts: The Review Team endorses
the 2020 NEAP plan to exclude all Tier 2 districts from CBV strategy. Timeline: this is should
be done by June 2020

VI.2 Recommendations on vaccination strategy options

i. Tier 1 Districts: The Review Team recommends the transition to Special Mobile Team (SMT)
strategy for all UCs in Tier 1 districts that are recommended above to be excluded from CBV
strategy, as the SMT strategy will enable better synchronization and uniformity with neighboring
CBV UCs in terms of duration of vaccination campaigns and catch-up of missed children (i.e. 5+2
days for both SMT and CBV strategies as per 2020 NEAP).
ii. Tier 2 Districts: The Review Team recommends the transition to Mobile Team (MT) strategy for
all UCs in Tier 2 districts that are recommended above to be excluded of CBV strategy, as MT
strategy will re-establish a uniform vaccination strategy across all Tier 2 districts of KP.

VI.3 Recommendations on addressing the risks associated with CBV transition

Change from CBV to alternate strategy would require careful assessment of political, managerial and
operational challenges. Risk mitigation plans and measures should be put in place well in advance of any
change. Specific recommendations:

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i. Strong leadership by national and provincial Governments, ownership of district administration

and engagement of local influential would be key elements of smoother and successful
transition. As such, respective Commissioners and DCs should be given detailed briefing on the
need for scaling down and strategy shift for further taking up with the community, and local
political leadership and community influencers be taken on board by the DCs.
ii. Community sensitization sessions should be organized to maintain trust of communities and
community influentials in areas where the CBV strategy will be transitioned to SMT or MT.
iii. All efforts should be made to retain high-performing FLWs, acknowledge their contributions and
encourage them to continue as part of SMT or MT strategy. In addition, government should
consider other mechanisms to absorb this trained work force starting from areas which will be
excluded of CBV strategy.
iv. Government should consider scaling up engagement of Lady Health Workers to serve as MT
during vaccination campaign in their assigned areas.

VI.4 Recommendations on government leadership and oversight

i. Government leadership at all levels is key to success. As such, Commissioners and Chief
Secretaries should provide regular oversight to the programme with focus on CBV areas and
government should ensure the placement of high-performing DCs in CBV districts. Learning
lessons from the COVID-19 experience, the District Administration in CBV areas should be driving
and leading the PEI activities and conducting critical reviews of each SIA.
ii. Department of Health, particularly District Health Officers and their teams should be held
accountable for performance and operation in their assigned areas.

VI.5 Recommendations on CBV support for essential immunization

i. As per their TORs, between campaign days CBV staff should focus on referral of
under/unimmunized children to EPI centers, identification and referral of newborns and support
of EPI teams in tracking of defaulters.
ii. National and Provincial EOCs should ensure the establishment of effective linkages between CBV
staff, Lady Health Workers and EPI centers in their assigned areas, as part of integration.
iii. All CBV staff should engage in RI mico-planning and organization of outreach sessions in their
assigned areas.

VI.6 Recommendations on transforming CBV to a more effective strategy

i. Recent management review of the programme recommended transformative changes in the

structure, processes, people and data system. The programme should accelerate the roll-out
of these recommendations to turn around the situation in CBV areas, including conducting
trainings to build managerial capacity of district and UC level staff and the establishment of
a performance management system that standardizes accountability across the CBV third
party vendors.
ii. The programme should review the profile and managerial capacity of CBV district and
provincial managers and replace where necessary—while structure and processes are
important, it is the people who make a difference. Start this process in the 40 Super High-
Risk UCs (SHRUCs).

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iii. In Quetta block and Peshawar all efforts should be made to ensure area supervisors of CHWs
are also females. Those CHWs who are experienced and fulfill the eligibility criteria should be
promoted as area supervisors in their respective areas. This will also minimize the
harassment/exploitation challenge by male supervisors in some of the areas.
iv. It would be critical to hold sensitization sessions with FLWs to renew and boost their morale
v. Strong supervision and regular validation should be done to ensure that all eligible children
are registered and vaccinated.
vi. The programme should sensitize and provide guidelines to supervisors and FLWs on safe
reporting of FFM.
vii. There should be a system to support the 3rd party in the implementation at the district and
provincial level. Innovative multiagency (GPEI partners & GoP) coordination mechanisms
should be tailored and implemented for this purpose.
viii. The Review Team acknowledges and fully supports the planned strategic improvements in
the overall C4E strategy. The Review Team further acknowledges that the new social
mobilisation structure is being implemented only in the highest risk areas of SHRUCs and not
in the entire SHRUC. For this reason, the programme needs to have a robust and ‘sensitive’
M & E strategy in place to track and measure not only the community trust building activities
being implemented but also clearly understand their impact on community perceptions and
ultimately on vaccination coverage.

VII. Acknowledgements
The Review Team would like to thank the staff from the NEOC, PEOCs, districts and UCs that participated
in the interviews and focus group discussions. The Review Team would also like to thank Raabya Abu
Zafar, Waqar Ahmed, Britta Tsang, Marcus Mayers and Achouak Majdoul for their valuable support.

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Annex 1: Data Collected for the Desk Review of the Pakistan CBV Strategy Review

1. Excel table of all CBV UCs by districts and by province with [at least] the following fields:
a. Total population
b. Target population
c. Number of CBV staff (CHWs, supervisors, UCCSOs, etc.) – a different column for each
cadre
d. Indication of which UCs are part of the current NEAP 2020 reduction plan
e. A column that captures how many of CHWs are female
f. A column that captures how many of the CHWs are from the community (e.g. tribe/sub-
tribe, language, religion/sect, etc.)
2. Maps
a. National map indicating current CBV Districts & UCs
b. National map indicating CBV Districts & UCs after implementing current NEAP 2020
reduction plan
c. Karachi map indicating current CBV Districts & UCs – this will be the whole of Karachi
d. Karachi map indicating CBV Districts & UCs after implementing current NEAP 2020
reduction plan
e. KP map indicating current CBV Districts & UCs
f. KP map indicating CBV Districts & UCs after implementing current NEAP 2020 reduction
plan
g. Peshawar map indicating current CBV UCs
h. Peshawar map indicating CBV UCs after implementing current NEAP 2020 reduction
plan
i. Quetta Block map indicating current CBV Districts & UCs
j. Quetta Block map indicating CBV Districts & UCs after implementing current NEAP 2020
reduction plan
3. SIAs performance analysis of the past 8 NIDs (excluding April 2019 and all campaigns that were
partially implemented for any reason)
a. Sindh, Baluchistan and KP provinces data comparing into CBV UCs vs SMT UCs vs MT
UCs
b. For each NID data must include at least:
i. Admin coverages
ii. ICM clusters coverages
iii. PCM coverages
iv. Proportion of lots passing LQAS assessment
v. Same day coverages
vi. Proportion of still missed children against: 1. Targeted and, 2. Recorded
vii. Proportion of still refusal children
viii. Number of AFP cases identified during each campaign
ix. Number of RI zero dose children recorded in each campaign
x. Number of RI zero dose children tracked and confirmed as vaccinated
4. SIA data to compare the performance of the programme in the same UC before CBV and after
CBV in Karachi, Quetta and Peshawar cities ONLY, we would want to compare 8 NIDs before the
start of CBV strategy with 8 NIDs after the start of CBV. We will exclude the first 2 NIDs after the
start of the CBV strategy (the changing period) out of the analysis. For each NID before and after
the CBV strategy we would like to see the following:
a. Admin coverages

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b. ICM clusters coverages

c. PCM coverages
d. Proportion of lots passing LQAS assessment
e. Same day coverages
f. Proportion of still missed children against: 1. Targeted and, 2. Recorded
g. Proportion of still refusal children 1. Targeted and, 2. Recorded
h. For each district we would like to see the trend of WPV cases in the past 10 years (Jan
2010 to Dec 2019)
5. Cost analysis will be carried to ascertain the differences in expenditure between the three
vaccination strategies (i.e. CBV vs SMT vs MT). To accomplish this, the Review Team will request
the following from the NEOC
a. Cost of vaccinating one child in an urban UC that is implementing CBV strategy
b. Cost of vaccinating one child in an urban UC that is implementing SMT strategy
c. Cost of vaccinating one child in an urban UC that is implementing MT strategy
d. Cost of maintaining of one CHW for one month
e. Cost of hiring one SMT vaccinator for one NID
f. Cost of hiring one MT vaccinator for one NID
g. Cost of maintaining of one CHW supervisor for one month
h. Cost of hiring one SMT team supervisor for one NID
i. Cost of hiring one MT team supervisor for one NID
j. Cost of logistics associated with CBV strategy for one urban CBV UC for one NID
(transport, TSC, registers, cold chain, forms, IECs, etc.)
k. Cost of logistics associated with SMT strategy for one urban SMT UC for one NID
(transport, tally sheets, cold chain, forms, IECs, etc.)
l. Cost of logistics associated with MT strategy for one urban MT UC for one NID
(transport, tally sheets, cold chain, forms, IECs, etc.)
m. All other cost associated with one CBV UC not mentioned above
n. All other cost associated with one SMT UC not mentioned above
o. All other cost associated with one MT UC not mentioned above
p. Tehsil and district level costs that are unique to the implementation of CBV strategy
q. Data management cost for a fully CBV urban district
r. Data management cost for a fully SMT urban district
s. Data management cost for a fully MT urban district

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Annex 2: Facilitator guide for the Pakistan Community Based Vaccination Strategy Review

1. As we understand the original driver for the establishment of CBVs was to overcome the then
prevailing security situation in Karachi and thinking was local women would have a better access
in those circumstances. Purely from security perspective in the current circumstances do the
CHWs have advantage over MTs?
2. In relation to the above question, there was the understanding the programme wanted to
reduce large LEA/Rangers footprint during SIAs did this actually happen?
3. In the Quetta Block, paramedical strikes by government workers were negatively impacting the
ability of the programme to implement SIAs. (relevant to National and Baluchistan team)
a. Is this still valid?
b. If paramedical strikes are still a constraint, is replacing government managed staffing
still an appropriate solution?
4. Another driver for “outsourcing” vaccination teams was to reduce/eliminate ghost teams, to
improve the selection of team members (e.g. gender-appropriate, age-appropriate, language-
appropriate, etc.), and to increase accountability of teams (e.g. showing up to work when they
should consistently across SIAs).
a. Does the maturity of the EOC structures and the ongoing programme Transformation
obviate the need to “outsource” cadres of polio staff?
b. In the spirit of “government ownership” is it appropriate for partner agencies to “own”
the vaccinators?
c. How does the use of 3rd parties impact accountability? Is it appropriate for 3rd parties
to “own” the hiring/firing/selection/supervision of the KEY frontline workers?
d. Is there an advantage of CBV over SMT/MT if SMT/MT teams are not government staff?
5. What are the criteria set by the programme to select UCs that will have CBV? Is it automatic that
all UCs in Tier 1 districts are CBV or is there a distinction between tier classification and CBV
deployment?
6. Was there any political pressure to expand CBV, or was part of the expansion for programmatic
expediency (regarded as easier to manage one approach across a geographic area)?
a. For example, what guided the programme when it decided to make ALL UCs of Karachi
CBV?
b. Did the footprint of CBV expand to UCs for reasons other than a real need for this
approach?
7. We understand CBV is deployed in the hardest areas and it is natural that it will be difficult for
CBV (or any approach) to be successful in such areas, but can we say that CBV is really fit for
purpose in tackling those difficult areas?
a. If, for example, a difficult area continues campaign after campaign to have high refusal
numbers, what is the benefit of CBV in that area?
b. Even if we say CBV areas have fewer refusals because of CBV, since we are going for
eradication, just a little better may not mean that CBV is fit for purpose of eradication.
Do you agree with that statement?
c. We understand that the May 2019 C4E review pointed out that CHWs were ‘consumed’
by operations leaving no time for CE and there was a proposal in strategic shift to
allocate more time for C4E. Do you believe this shift has taken place and if yes, can you
explain the impact this shift had on the ground?
8. What are the most critical functions which are currently performed by CBV but can’t be done
through other strategies like SMT or MT?

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9. According to NEAP 2020, all areas/UCs where CBV will be scaled down will be transitioned to
special mobile teams (SMT). Why to SMT and why not to MT strategy?
10. What risks and potential sensitivities can be expected when/if CBV strategy is shifted to SMT or
MT—performance risks, how FLWs can react? political risk etc.?

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Annex 3: Online survey for Key Technical Staff in CBV (ODK)

Dear colleague: We are conducting a review of the Community-Based Vaccination (CBV) strategy in
Pakistan to inform programmatic decisions to be taken by the national emergency operation center. As
part of this exercise we would like to hear your opinion on some aspects of the CBV strategy. We would
like to thank you for taking the time to complete this questionnaire. The information you provide will not
be related back to you as an individual, we will not collect your name or any other identifiers except
geographical and organizational information that will help us understand the results of the questionnaire
better.
1. Date of questionnaire completion (to be collected automatically)
2. Geocode (to be collected automatically)
3. Would you like to proceed to the questions? Yes, or No. if yes, proceed to question 4. if no, end
the questionnaire
4. What is your duty level?
a. National
b. Provincial; choose your province from the list
c. District; choose your district from the list
d. UC; choose your UC from the list
5. Organization: Government, WHO, UNICEF, NSTOP, other (specify: _____)
6. According to you what value in terms of programme performance did the introduction of the
CBV strategy add in Pakistan or in your province/district/UC? Choose one;
a. Performing worse than the MTs
b. No value added
c. Minimal improvement on what MTs used to do
d. Much improvement on what MTs used to do
7. How did the CBV strategy improve the following on a scale of 1 to 5, with 1=deteriorated, 2=no
change, 3=minimal improvement, 4=moderate improvement and 5=very high improvement?
a. Microplanning
b. Workload rationalization
c. Community acceptance and community trust
d. Social mobilization
e. Missed children coverage
f. Overall programme quality
8. How do you think the CBV programme was managed? Pick one;
a. Poorly managed
b. Managed just like the other campaign strategies
c. Better managed
9. Is the repeated micro-census done by CHWs necessary? Yes, or No
10. Is it appropriate for the CHWs to re-do their microplans every month? Yes, or No
11. Is there sufficient time for CHWs to carry out IPC and CE in-between campaigns? Yes, or No
12. Are CHWs receiving appropriate training and supportive supervision to perform their duties?
Yes, or No
13. C4E review recommended more time for CE in the CBV strategy and introduction of expanded
communication topics (KHP). Do you think this will have a positive impact on community trust
and acceptance? Yes, or No
14. Is it a good practice to have all UCs in Tier 1 districts to be CBV? Yes, or No
15. Is there need to distinguish between tier classification and CBV deployment? Yes, or No

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16. Is it always easy to find the right CHWs and CHW supervisor where they are needed was
problem - local woman who belong and speak the language of the communities they work for?
Yes, or No
17. How would you characterize the selection of the CHWs and CHW supervisor?
a. Always appropriate
b. Mostly appropriate
c. Rarely appropriate
d. Never appropriate
18. Did the CBV strategy contribute in the improvement of routine immunization in the UCs where
the strategy is being implemented? Yes, or No
19. Do you believe implementation of CBV in the high-risk UCs will lead to eradication? Yes, or No

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Annex 4 – Areas covered by CBV by risk tier (Figure A) and by 2020 NEAP retention status (Figure B)

Retained CBV UCs

Excluded CBV UCs

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Annex 5 – Revised district and UC structure for Tier 1 districts following the Management Review

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Annex 6 – Distribution of CBV human resources (Table A) and workload (Table B), by Province

Table A: Distribution of CBV staff

Table-1:by Province
Distribution of human resources working in the CBV strategy in Pakistan
Provincial Level HR District Level HR UC Level HR

Province CBV Lead Master Grand Total Deployed

PTC PDA Total DHCSO's DSO Total UCCSO AS CHWs Total
Manager Trainer Trainer
Deployed Deployed Deployed Deployed Deployed Deployed Deployed Deployed Deployed Deployed
Deployed Deployed Deployed
BALOCHISTAN 5 1 1 7 - 11 23 24 58 158 803 3,096 4,057 4,122
KP 4 2 2 8 - 10 22 20 52 270 1,328 4,740 6,338 6,398
SINDH 1 1 2 4 3 30 45 45 123 419 2,554 11,648 14,621 14,748
NATIONAL 10 4 6 19 3 51 90 89 233 847 4,685 19,484 25,016 25,268

Table B: Distribution of workload by Province

Table-2: Distribution of the workload for district and UC staff in CBV areas of Pakistan
# of # of
# of # of CHW # of AS # of CHW # of AS # of # of
children # of children # of CHW UCCSO
Province children per per per per children children per
per HR per CHW per AS per
per AS UCCSO UCCSO DHCSO DHCSO per UCCSO DHCSO
position DHCSO
BALOCHISTAN 983 222 4 858 20 5 135 35 7 4359 28694
KP 1140 262 4 934 18 5 215 60 12 4594 62015
SINDH 890 192 5 873 28 6 259 57 9 5324 49572
NATIONAL 968 213 4 888 23 6 216 52 9 4911 46738

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Annex 7 – LQAS Trends, CBV areas, 2015-2019

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Annex 8 – Reorganisation of processes to build more time for community engagement

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