Cell Coverage: Reaching Pakistan’s Children with the Polio Vaccine

Digital-Diversity-BannerPakistan is one of only two remaining polio-endemic countries, and extinguishing the virus from every remote region is a considerable challenge. Vaccinators, risking attacks from militants, have to target and track with precision civilians fleeing a warzone in the country’s northwest provinces. One project is using cell phones as part of the polio eradication effort, and the potential is great for improved public health in general. A 2012 report predicted that mobile health technologies could save 75,000 mothers and children every year in Pakistan, and reduce hospital costs by US$1 billion annually, through accurate remote diagnostics that ensure treatment at the right level, reducing hospital referrals.

Digital Diversity is a series of blog posts from kiwanja.net featuring the many ways mobile phones and other appropriate technologies are being used throughout the world to improve, enrich, and empower billions of lives.

By Aziz Memon

In 2014, nearly a million people were displaced by the government’s military operation to root out terrorists in northwestern Pakistan. Inevitably, this massive migration caused challenges as fleeing families reached refugee camps and new communities. Pakistan is one of only two remaining polio-endemic countries, and polio infection rates soared in 2014, with 306 cases, the highest number in over a decade.

But it also opened up a window of opportunity to vaccinate more than 850,000 children who had not been accessible to health workers since 2012. With so many children missed by Pakistan’s polio vaccination effort, the country needed to conduct a swift, precise campaign to ensure that a devastating disease did not spread further.

And this is where the potential of cell phones for public health enters the picture. Since April 2014, Rotary has been working in Pakistan to replace traditional written paper reporting of polio and maternal and newborn health data from the field with cell phone reporting.

In the words of Project Manager Asher Ali, “In view of the mass migration during the fighting, coverage of missed children since 2012 was a challenge and we needed new techniques to overcome this problem. We need to trace these children in high risk areas and make sure they are vaccinated.”

The use of cell phones for public health projects is increasingly widespread, as other posts on this blog prove, but there are also well known obstacles to effective implementation. As revealed in a new Humanitarian Technologies Project report, top-down initiatives — such as those following Typhoon Haiyan in 2013 — pursued without community feedback and a consideration of local human needs simply fall short of successful humanitarian interventions.

This is why Rotary was so careful not to impose a purely technological approach with its cell phone project in Pakistan, which is led and implemented entirely by volunteer community leaders.

First, local needs were rigorously assessed. Polio eradication requires comprehensive nationwide campaigns, and in Pakistan, this means targeting all of the more than 35 million children under the age of five. Pakistan recognized that children in inaccessible areas like North and South Waziristan and Khyber Pakhtunkhwa were ‘continuously missed’ by health workers. Yet serious gaps in vaccine coverage and accountability also applied to areas that vaccinators could reach without obstacles. In the highest risk districts, 48% of missed children are not seen simply because a team did not visit them. And when families are reached, a limited number refuse vaccines due to a number of factors, from lack of information, to religious and cultural objections, or the pressure of extremists.

To overcome these challenges, Ali chose an approach that integrated two key factors: appropriate technology and human capacity building.

An e-monitoring training session in Peshawar for 30 Community Midwives in January 2016. Photo courtesy of the author
An e-monitoring training session in Peshawar for 30 Community Midwives in January 2016. Photo courtesy of the author

First, Rotary partnered with Telenor, the second largest mobile operator in Pakistan, Eycon Ltd (a data monitoring and evaluation specialist), and local governments to provide phones and training to Lady Health Workers and Community Midwives through multiple districts in Pakistan.

Lady Health Workers are employed extensively by the polio eradication effort as they are trusted to enter households and have the interactions with mothers and children necessary to deliver the polio vaccine. They also provide health education and services for antenatal care, routine immunization, and maternal health. The cell phone project had to ensure that these women were well trained in the use of the technology, as we know that mobile data collection ‘is only as effective as the staff applying it’.

At training sessions, Lady Health Workers and Community Midwives were taught how to record data on the phones and log daily reports to create a database.

The project allows health workers and public health facilities to better collect more accurate data from the field in real-time allowing for swift monitoring and better strategic analysis of the data. The traditional practice of collecting and reporting all Mother & Child and Immunization data in hard form by health workers on a weekly or monthly basis was inadequate for policy makers and polio eradication partners to plan and implement programs effectively.

The new real-time reporting and analysis allows the polio program to rapidly respond to immunization gaps and address challenges in accessing hard-to-reach children. The data collected and reported on the cell phones includes Maternal, Newborn & Child Health indicators (deliveries, newborn deaths, maternal deaths, etc.) and immunization indicators e.g., polio immunizations administered, polio immunizations refused and the reason e.g., fear, religious objections, lack of awareness, etc.

And the progress is striking, both in the quality of reporting by health workers and the vaccine coverage achieved through acting on this new data. The chart below shows the response in one district, Nowshera, tracking both the number of reporting health workers and their use of the cell phones:


With improved reporting from health workers, the polio eradication partners were able to look at maternal and child health indicators, and polio eradication progress, in more detail:

Detailed reporting by health workers using the cell phones allows planners to track immunization coverage and the number of referrals to secondary health centers.

With better knowledge of the reasons for resistance to polio vaccines in specific regions, Rotary has been able to adapt its existing strategies appropriately, such as engaging religious and community leaders to educate them about the importance of vaccinating children, to enlist their support in promoting the safety of the vaccine, and to build public trust in health services.

Nationwide, 533 Lady Health Workers and Community Midwives have been trained as part of the project across nine districts, and they have logged over 32,000 log reports since its rollout in April 2014.

And with improved data collection, quality and analysis, Pakistan is making notable progress in its battle against polio, reducing its caseload to just 52 in 2015, compared to 306 the previous year.

Ali sees broader health care applications for his cell phone project, such as reducing Pakistan’s high maternal and infant mortality rates, and if it generates further success, his plan is to “extend it to cover more health workers and link it to the National Database Registration Authority” to enhance routine immunization efforts.

But polio is his most pressing concern, and when I asked him about the significance of the project this month, he had high hopes: “If we can interrupt the transmission of polio in Pakistan in 2016, we are closer to eradicating a human disease for only the second time in history. This is something that should excite everyone and would be the best tribute to the Lady Health Workers taking risks in the field every day to reach our nation’s children.”

azizmemonAziz Memon is the Chairman of the National Polio Plus Committee, Pakistan, for Rotary International, and has dedicated his time and resources to completely eradicating polio from Pakistan. The cell phone project described by this article is sponsored by Rotary, one of the top 5 global nonprofits, which brings together business and community leaders to address the world’s most pressing humanitarian challenges.

Digital Diversity is produced by Ken Banks, innovator, mentor, author, anthropologist, National Geographic Emerging Explorer and Founder of kiwanja.net, FrontlineSMS and Means of Exchange. He shares exciting stories in Digital Diversity about how mobile phones and appropriate technologies are being used throughout the world to improve, enrich, and empower billions of lives. You can follow him on Twitter @kiwanja



Meet the Author
Ken Banks is an innovator, mentor, anthropologist and National Geographic Emerging Explorer. Founder of kiwanja.net and now Head of Social Impact at Yoti, he spends his time applying Yoti's digital identity solutions to humanitarian problems around the world. His earlier research resulted in the development of FrontlineSMS, an award-winning text messaging-based field communication system designed to empower grassroots non-profit organisations. He shares exciting stories in "Digital Diversity" about how mobile phones and other appropriate technologies are being used around the world to improve, enrich, and empower billions of lives.