Report of

Profiles of Slums and Underserved Areas

of Five Largest Cities of Punjab, Pakistan

July 2020

Acknowledgments

This study was conducted with the technical support and oversight from UNICEF Immunization team Pakistan, with financial support of Gavi- the vaccine alliance and executed by Civil Society Human and Institutional Development Programme (CHIP) under the leadership of Provincial and Federal EPI programs. The report in hand presents the results of ‘Profiling of Urban Slums/Underserved Areas’ held in 08 largest cities of Pakistan. Our sincere thanks to UNICEF for their technical support throughout the process to achieve the planned results. Our sincere thanks to UNICEF & WHO Country office colleagues, CSOs and expanded partners for their technical support and facilitation to complete this assignment. Special acknowledgement is extended to Federal EPI Programs, Provincial EPI and District Department of Health who extended their leadership and fullest cooperation for the successful execution of the survey. Specific acknowledgement is also extended to all the respondents for participating in this study and adding their valuable input to this discourse. It would not have been possible to present such in-depth, relevant and reliable information without their cooperation.

Table of Contents Executive Summary .............................................................................................................................................. 1 Chapter 1: Introduction ................................................................................................................................. 3

1.1 Introduction ............................................................................................................................................ 3 1.2 Initiatives for Slum-Dwellers by the Private Sector ................................................................................ 6 1.3 Objectives .............................................................................................................................................. 6 1.4 Rationale ............................................................................................................................................... 6

Chapter 2: Methodology................................................................................................................................ 8

2.1 Study Design ......................................................................................................................................... 8 2.2 Study Sites ............................................................................................................................................ 8 2.3 Study Duration ....................................................................................................................................... 8 2.4 Study Respondents ............................................................................................................................... 8 2.5 Sampling Procedures and Sample Size ................................................................................................ 9 2.6 Key Variables ...................................................................................................................................... 12 2.7 Data Collection Instruments ................................................................................................................. 12 2.8 Operational Definitions ........................................................................................................................ 12 2.9 Data Analysis Techniques ................................................................................................................... 14 2.10 Monitoring Mechanism......................................................................................................................... 14 2.11 Study Team and Training .................................................................................................................... 15

Chapter 3: Profiling of Slums and Underserved Areas ............................................................................ 17

3.1 Slums and Underserved Areas ............................................................................................................ 17 3.2 Demography ........................................................................................................................................ 19 3.3 Health and Epi Resources ................................................................................................................... 20 3.4 Infrastructure ....................................................................................................................................... 23 3.5 Social Welfare Services ....................................................................................................................... 27

Chapter 4: Health and EPI Resources at Union Council of Punjab ......................................................... 30

4.1 Administrative Layout .......................................................................................................................... 30 4.2 Healthcare Facilities ............................................................................................................................ 31 4.3 EPI Centers ......................................................................................................................................... 31 4.4 Equipment and Supplies ...................................................................................................................... 32 4.5 Human Resources ............................................................................................................................... 32 4.6 Nutrition Services ................................................................................................................................ 33

Chapter 5: EPI Facilities .............................................................................................................................. 36

5.1 Infrastructures ...................................................................................................................................... 36 5.2 System ................................................................................................................................................. 37 5.3 Management and Facilities .................................................................................................................. 37 5.4 Equipment and Supplies ...................................................................................................................... 39 5.5 Waste Management............................................................................................................................. 40 5.6 Human Resources ............................................................................................................................... 41

Chapter 6: Childhood Vaccination ............................................................................................................. 43

6.1 Vaccination Coverage.......................................................................................................................... 44 6.2 Characteristics of the Mothers ............................................................................................................. 49 6.3 Characteristics of the Households ....................................................................................................... 49 6.4 Characteristics Of Fully Immunized Vs. Zero Dose Children ............................................................... 51

Chapter 7: Conclusion ................................................................................................................................ 54

7.1 Conclusion ........................................................................................................................................... 54 7.2 Study Limitations ................................................................................................................................. 54

Chapter 8: Recommendations .................................................................................................................... 57

8.1 Service Delivery ................................................................................................................................... 57 8.2 Demand Generation and Communication............................................................................................ 57 8.3 Health Work Force ............................................................................................................................... 57 8.4 Gender in Immunization ....................................................................................................................... 57 8.5 Practical vs. Strategic Needs ............................................................................................................... 57 8.6 Others .................................................................................................................................................. 58

Annex 1: Questionnaire for Group Interviews in Slums & Underserved Areas ....................................... 59 Annex 2: Questionnaire for Household Coverage Survey ......................................................................... 66 Annex 3: Questionnaire for District or Town Health Office ....................................................................... 71 Annex 4: Questionnaire for EPI Center Assessment ................................................................................. 73 Annex 5: Analysis of Profiling of Slums/Underserved Areas ................................................................... 75 Annex 6: Analysis of Health Resources of Union Councils ...................................................................... 86 Annex 7: Analysis of Results of EPI Facility Assessment ......................................................................... 89 Annex 8: Analysis of Household Coverage Survey ................................................................................... 92

List of Tables Table 1: Respondents of the Study .................................................................................................................................. 8 Table 2: Inclusion and Exclusion Criteria .......................................................................................................................... 9 Table 3: Key Variables In The Study .............................................................................................................................. 12 Table 4: Vaccination schedule ........................................................................................................................................ 14 Table 5: Categories of slums data .................................................................................................................................. 14 Table 6: Total Number Of Slums And Underserved Areas In Study Sites ....................................................................... 18 Table 7: Total Number Of Registered And Unregistered Slums In Study Sites ............................................................... 18 Table 8: Total Population In Slums And Underserved Areas In Study Sites .................................................................... 19 Table 9: Total Population Of Children Aged Between 0 And 11 Months [(3.5% And 92% Survival)]................................ 19 Table 10: Total Population Of Children Under Five Years Of Age ................................................................................ 19 Table 11: Total Population Of Women Of Child-Bearing Age ....................................................................................... 19 Table 12: Total Population Of Permanent Residents Of Slums And Underserved Areas ............................................. 20 Table 13: Total Population Of Temporary Displaced .................................................................................................... 20 Table 14: Total Population Of Residents Belonged To Other Nationalities ................................................................... 20 Table 15: Union Councils With And Without Public Healthcare Facilities ..................................................................... 20 Table 16: Union councils with and without EPI centers ................................................................................................ 21 Table 17: Provision of outreach vaccination services in slums and underserved areas ................................................ 21 Table 18: Percentage of uncovered areas in slums and underserved by LHWs ........................................................... 21 Table 19: Percentage Of Non-Presence Of Dengue Workers In Slums And Underserved Areas ................................. 22 Table 20: Percentage of residents of slums and underserved areas unaware of 1122 services ................................... 22 Table 21: Percentage of residents of slums and underserved areas unaware of 1038 services ................................... 22 Table 22: Percentage of slums and underserved areas without the school facility ....................................................... 27 Table 23: Percentage of slums and underserved areas with presence of government schools .................................... 27 Table 24: Percentage of slums and underserved areas with the presence of civil society organisations ...................... 27 Table 25: Percentage of slums and underserved areas with the presence of informal groups ..................................... 28 Table 26: Percentage Of Slums And Underserved Areas With The Availability Of Public Welfare Schemes ................ 28 Table 27: Total Numbers Of Towns And Union Councils In Study Areas ..................................................................... 30 Table 28: Total Number Of Union Councils That Housed Slum Areas ......................................................................... 30 Table 29: Total Population and Union Councils Housed by Slums and Underserved Areas ......................................... 31 Table 30: Total Number Of Union Councils With And Without Healthcare Facilities ..................................................... 31 Table 31: Total number of healthcare facilities vs union councils ................................................................................. 31 Table 32: Number Of Fixed EPI Centers In Union Councils ......................................................................................... 31 Table 33: Number of union councils with or without fixed EPI centers ......................................................................... 32 Table 34: Total Number of EPI Centers with Functional Ice Lined Refrigerators .......................................................... 32 Table 35: Total Number Of Union Councils Covered and Uncovered by LHWs ........................................................... 32 Table 36: Total Number of LHWs Deployed in Covered Areas .................................................................................... 32 Table 37: Total Number of Dengue Workers in all Union Councils ............................................................................... 33 Table 38: Total Number of Active Vaccinators in all EPI Centers ................................................................................. 33 Table 39: Total Number Of Union Councils With Nutrition Service Deliveries .............................................................. 33 Table 40: Type of Nutrition Services Delivered in all Union Councils ........................................................................... 34 Table 41: Percentage of gender mixed and segregated waiting areas in EPI centers .................................................. 37 Table 42: Percentage of seating capacity in waiting areas for female caregivers in EPI centers .................................. 38 Table 43: Percentage Of EPI Centers With and Without Functional Ice Lined Refrigerators ........................................ 39 Table 44: Percentage Of EPI Centers Faced Problem In Getting Vaccines During Last One Year .............................. 40 Table 45: Units of Analysis in the Childhood Vaccination Coverage Survey................................................................. 44 Table 46: Reasons Of Zero Dose Children .................................................................................................................. 48 Table 47: Fully Immunized Children Vs. Children With Zero Dose in Houses Without Toilet Facilities ......................... 52 Table 48: Number of Slums and Underserved ............................................................................................................. 75 Table 49: Timeframe Existence of Slums .................................................................................................................... 75 Table 50: Registration Status of Slums ........................................................................................................................ 75 Table 51: Population ................................................................................................................................................... 75 Table 52: Types of Residents in Slums........................................................................................................................ 75 Table 53: Types of Residents in Underserved ............................................................................................................. 75 Table 54: Types of Residents in Slums and Underserved (Total)................................................................................. 75 Table 55: Number of Health Facilities .......................................................................................................................... 76 Table 56: Slums having Private and Public Health Facilities ........................................................................................ 76 Table 57: Underserved having Private and Public Health Facilities .............................................................................. 76 Table 58: Slums and Underserved having Private and Public Health Facilities ............................................................ 76 Table 59: Average Distance between Private Health Facilities and Slums ................................................................... 76 Table 60: Average Distance between Private Health Facilities and Underserved......................................................... 76 Table 61: Average Distance between Private Health Facilities and Slums/Underserved (Total) ................................... 76 Table 62: EPI Facilities ................................................................................................................................................ 77 Table 63: Distance Between EPI Facilities and Slums ................................................................................................. 77 Table 64: Distance Between EPI Facilities and Underserved (Total) ........................................................................... 77 Table 65: Distance Between Fixed EPI Facilities in Slums and Underserved (Total) ................................................... 77 Table 66: Outreach of Vaccination Services in Slums .................................................................................................. 77 Table 67: Outreach of Vaccination Services in Underserved ....................................................................................... 77 Table 68: Outreach of Vaccination Services in Slums/Underserved (Total).................................................................. 77 Table 69: Lady Health Worker in Slums ...................................................................................................................... 77 Table 70: Lady Health Worker in Underserved ............................................................................................................ 78 Table 71: Lady Health Worker in Slums/Underserved (Total) ...................................................................................... 78 Table 72: Availability of 1122 Services ........................................................................................................................ 78 Table 73: Availability of 1038 Services ........................................................................................................................ 78 Table 74: Dengue Workers .......................................................................................................................................... 78

Table 75: Types of Housing Structure in Slums ........................................................................................................... 78 Table 76: Types of Housing Structure in Underserved ................................................................................................. 78 Table 77: Types of Housing Structures in Slums/Underserved (Total) ......................................................................... 79 Table 78: Sources of Domestic Water in Slums ........................................................................................................... 79 Table 79: Sources of Domestic Water in Underserved................................................................................................. 79 Table 80: Sources of Domestic Water in Slums/Underserved (Total) ........................................................................... 79 Table 81: Duration of Water Availability (in case of Government Water Supply) in Slums ............................................ 79 Table 82: Duration of Water Availability (in case of Government Water Supply) in Underserved.................................. 79 Table 83: Duration of Water Availability (in case of Government Water Supply) in Slums/Underserved (Total) ............ 79 Table 84: Availability of Household Toilets in Slums .................................................................................................... 80 Table 85: Availability of Household Toilet in Underserved ........................................................................................... 80 Table 86: Availability of Household Toilet in Slums/Underserved ................................................................................. 80 Table 87: Type of Household Toilet in Slums ............................................................................................................... 80 Table 88: Type of Household Toilet in Underserved .................................................................................................... 80 Table 89: Type of Household Toilet in Slums/Underserved (Total) .............................................................................. 80 Table 90: Average # of People using Toilet ................................................................................................................. 80 Table 91: Average # of People using Toilet in Underserved......................................................................................... 80 Table 92: Average # of People using Toilet in Slums and Underserved Areas (Total) .................................................. 81 Table 93: Modes of Defecation Without Toilet in Slums ............................................................................................... 81 Table 94: Modes of Defecation Without Toilet in Underserved ..................................................................................... 81 Table 95: Modes of Defecation Without Toilet in Slums/Underserved (Total) ............................................................... 81 Table 96: Condition of Drains in Slums ........................................................................................................................ 81 Table 97: Condition of Drains in Underserved ............................................................................................................. 81 Table 98: Condition of Drains in Slums and Underserved (Total) ................................................................................. 81 Table 99: Solid Waste Disposal Practices in Slums ..................................................................................................... 81 Table 100: Solid Waste Disposal Practices in Underserved ........................................................................................... 82 Table 101: Solid Waste Disposal Practices in Slums and Underserved (Total) ............................................................. 82 Table 102: Schools in Slums and Underserved ............................................................................................................. 82 Table 103: Schools in Slums and Underserved (Total) .................................................................................................. 82 Table 104: Types of Schools in Slums ........................................................................................................................... 82 Table 105: Types of Schools in Underserved ................................................................................................................ 82 Table 106: Types of Schools in Slums and Underserved Areas (Total).......................................................................... 82 Table 107: Distance of Nearest School from Slums ....................................................................................................... 83 Table 108: Distance of Nearest School from Underserved ............................................................................................ 83 Table 109: Distance of Nearest School and Slums/Underserved ................................................................................... 83 Table 110: Availability of Working by CSOs ................................................................................................................... 83 Table 111: Types of Services by CSOs in Slums ........................................................................................................... 83 Table 112: Types of Services by CSOs in Underserved Areas ...................................................................................... 83 Table 113: Types of Services by CSOs in Slums/Underserved Areas (Total) ................................................................ 83 Table 114: Presence of Informal Groups ....................................................................................................................... 84 Table 115: Type of Informal Groups in Slums ................................................................................................................ 84 Table 116: Types of Informal Groups in Underserved Areas ......................................................................................... 84 Table 117: Types of Informal Groups in Slums/Underserved Areas ............................................................................... 84 Table 118: Availability of Welfare Scheme by Government ............................................................................................ 84 Table 119: Types of Welfare Schemes by Government ................................................................................................. 85 Table 120: Town Wise Number of UCs with/ without Slums/ Underserved .................................................................... 86 Table 121: Status of Slums/Underserved in Union Councils .......................................................................................... 86 Table 122: Town wise Number of UCs and Population .................................................................................................. 86 Table 123: Population of UCs ........................................................................................................................................ 87 Table 124: Number of Health Facilities in UCs .............................................................................................................. 87 Table 125: UCs with/ without Health Facilities ............................................................................................................... 87 Table 126: Number of EPI Facilities .............................................................................................................................. 87 Table 127: UCs with/ without EPI Facilities .................................................................................................................... 87 Table 128: Availability of Functional ILR/Refrigerator in Fixed EPI Facility ..................................................................... 87 Table 129: Outreach Vaccination Services .................................................................................................................... 88 Table 130: Nutrition Services......................................................................................................................................... 88 Table 131: Types of Nutrition Services in UCs ............................................................................................................... 88 Table 132: Number of Vaccinators in Public Health Facilities ........................................................................................ 88 Table 133: Number of UCs Covered by LHWs .............................................................................................................. 88 Table 134: Availability of Dengue Workers .................................................................................................................... 88 Table 135: Number of EPI Facilities .............................................................................................................................. 89 Table 136: Status of Ownership of Building of EPI Facilities .......................................................................................... 89 Table 137: Types of EPI Facilities ................................................................................................................................. 89 Table 138: Average Working Hours of EPI Facilities ...................................................................................................... 89 Table 139: Availability of Standard Operating Procedures ............................................................................................. 90 Table 140: Availability of LHVs in EPI Facilities ............................................................................................................. 90 Table 141: Availability of Vaccinators in EPI Facilities ................................................................................................... 90 Table 142: Vaccine Supplies ......................................................................................................................................... 90 Table 143: Supply of Vaccines ...................................................................................................................................... 90 Table 144: Availability of Ice Lined Refrigerators ........................................................................................................... 90 Table 145: Availability of Waiting Areas ......................................................................................................................... 90 Table 146: Seating Capacity of Waiting Areas in EPI Facilities ...................................................................................... 91 Table 147: Availability of Drinking Water ....................................................................................................................... 91 Table 148: Availability of Toilets .................................................................................................................................... 91 Table 149: Usability of Toilet ......................................................................................................................................... 91

Table 150: Waste Management Practices ..................................................................................................................... 91 Table 151: Sample Size ................................................................................................................................................ 92 Table 152: Gender Wise Total Children ......................................................................................................................... 92 Table 153: Number of Children of Each Mother of Less Than 2 Year of Age ................................................................. 92 Table 154: Total Family Members with Gender Segregation.......................................................................................... 92 Table 155: Average Family Size .................................................................................................................................... 92 Table 156: Children with/without Vaccination Card ........................................................................................................ 92 Table 157: Fully Immunized Children (Records + Recall) .............................................................................................. 92 Table 158: Fully Immunized Children (Records) ............................................................................................................ 93 Table 159: Antigen Wise Coverage (Records + Recall) ................................................................................................. 93 Table 160: Antigen Wise Coverage (Records) ............................................................................................................... 93 Table 161: Partially Vaccinated Children (Records+ Recall) .......................................................................................... 93 Table 162: Gender of Partially Vaccinated Children on Record and Recall Basis .......................................................... 93 Table 163: Partially Vaccinated Children (Records) ....................................................................................................... 93 Table 164: Status of Zero Dose Children ....................................................................................................................... 93 Table 165: Reasons of Zero Dose Children ................................................................................................................... 94 Table 166: Perception of Mothers about Purpose of Vaccination of Children ................................................................. 94 Table 167: Knowledge of Mothers About Working of LHWs ........................................................................................... 94 Table 168: Types of Services Provided by LHWs (Perception of Mothers) .................................................................... 94 Table 169: Preferred Channels of Communication for Mothers ...................................................................................... 94 Table 170: Age Range of Mothers Surveyed ................................................................................................................. 94 Table 171: Years of Schooling Completed by Mothers .................................................................................................. 95 Table 172: Engagement of Mothers in Livelihood Activities ........................................................................................... 95 Table 173: Commonly Spoken Languages .................................................................................................................... 95 Table 174: Housing Structures ...................................................................................................................................... 95 Table 175: Number of Rooms per House ...................................................................................................................... 95 Table 176: Availability of Electricity................................................................................................................................ 95 Table 177: Sources of Water ......................................................................................................................................... 95 Table 178: Duration of Water Availability in Case of Government Water Supply ............................................................ 96 Table 179: Household Toilets ........................................................................................................................................ 96 Table 180: Average Users of One Toilet ........................................................................................................................ 96 Table 181: Modes of Defecation in the Case of Unavailability of Household Toilet ........................................................ 96 Table 182: Major Professions ........................................................................................................................................ 96 Table 183: Status of Financial Debt/Savings ................................................................................................................. 96 Table 184: Education Level of Mothers of Zero Dose Children ...................................................................................... 96 Table 185: Major Professions of Caregivers of Zero Dose Children ............................................................................... 97 Table 186: Status of Financial Debt/Savings in Households of Zero Dose Children ....................................................... 97 Table 187: Family Sizes of Zero Dose ........................................................................................................................... 97 Table 188: Housing Structures of Zero Dose Children ................................................................................................... 97 Table 189: Households Toilets in Zero Dose Children ................................................................................................... 97 Table 190: Modes of Defecation in the Absence of Toilets in the Houses of Zero Dose Children ................................... 97 Table 191: Education level of Mothers of Fully immunized Children .............................................................................. 97 Table 192: Major Professions of Caregivers of Fully Immunized Children ...................................................................... 98 Table 193: Status of Financial Debt/Savings in Households of Fully Immunized Children .............................................. 98 Table 194: Family Sizes of Fully Immunized .................................................................................................................. 98 Table 195: Housing Structures of Fully immunized Children .......................................................................................... 98 Table 196: Households Toilets in Fully Immunized Children .......................................................................................... 98 Table 197: Modes of Defecation in the Absence of Toilets in the Houses of Fully Immunized........................................ 98

List of Figures

Figure 1: Key Activities in The Study ................................................................................................................................. 8 Figure 2: Key Elements for Background Information of Respondents & Households........................................................ 10 Figure 3: Study team composition ................................................................................................................................... 15 Figure 4: Percentage of Union Councils with and without Slums / Underserved Areas .................................................... 17 Figure 5: Timeline of Emergence of Slums ...................................................................................................................... 18 Figure 6: Percentage of Unregistered Slums in Study Areas ........................................................................................... 18 Figure 7: Percentage of Kacha (Tented) Housing Structures in Slum and Underserved Areas ........................................ 23 Figure 8: Percentage of Kacha Pacca Housing Structures in Slum and Underserved Areas ............................................ 23 Figure 9: Percentage of Pacca Housing Structures in Slum and Underserved Areas ...................................................... 23 Figure 10: Percentage of Housing Structures Without Toilet Facilities .......................................................................... 24 Figure 11: Percentage of Housing Structures with Traditional / Open Pit Toilets .......................................................... 24 Figure 12: Type of Toilet - With Street Drain ................................................................................................................. 24 Figure 13: Percentage of Residents Used Ground Water ............................................................................................. 25 Figure 14: Percentage of Residents Used Government Water Supply .......................................................................... 25 Figure 15: Percentage of Residents Used Other Sources of Water ............................................................................... 25 Figure 16: System for Waste Water Disposal: Drains with Running Water ................................................................... 25 Figure 17: System for Solid Waste Disposal – Government .......................................................................................... 26 Figure 18: System for Solid Waste Disposal – Self ....................................................................................................... 26 Figure 19: System for Solid Waste Disposal: Throwing on Empty Plots / Streets .......................................................... 26 Figure 20: Percentage of EPI Centers Owned by the Government ............................................................................... 36 Figure 21: Percentage of EPI Centers without SOPs .................................................................................................... 37 Figure 22: Percentage of EPI Centers without Drinking Water Facility .......................................................................... 38 Figure 23: Percentage of EPI Centers with Toilet Facilities ........................................................................................... 38

Figure 24: Percentage of EPI Centers with Gender Segregated and Mixed Toilet Facilities .......................................... 38 Figure 25: Percentage of EPI Centers with Unusable Toilet Facilities ........................................................................... 39 Figure 26: Percentage of EPI Centers with less than 6 working hours .......................................................................... 39 Figure 27: Percentage of EPI Centers with Essential Supplies ..................................................................................... 40 Figure 28: Percentage of EPI Centers with Types of Waste Management .................................................................... 40 Figure 29: Percentage of EPI Centers who has LHVs ................................................................................................... 41 Figure 30: Retention of Vaccination Cards .................................................................................................................... 44 Figure 31: Fully Immunized Children (Record + Recall) ................................................................................................ 45 Figure 32: Fully Immunized Children (Records) ............................................................................................................ 45 Figure 33: Coverage Rates for BCG OPV 0 (Records + Recall).................................................................................... 46 Figure 34: Coverage Rates for Penta 1 (Records + Recall) .......................................................................................... 46 Figure 35: Coverage Rates for Penta 2 (Records + Recall) .......................................................................................... 46 Figure 36: Coverage Rates for Penta 3 (Records + Recall) .......................................................................................... 46 Figure 37: Coverage Rates for Measles I (Records + Recall) ....................................................................................... 46 Figure 38: Percentage of Defaulter for Penta 3 & Measles 1......................................................................................... 46 Figure 39: Antigen Wise Coverage (Records Basis) ..................................................................................................... 47 Figure 40: Partially Vaccinated (Records + Recall) ....................................................................................................... 47 Figure 41: Partially Vaccinated (Records Basis) ........................................................................................................... 47 Figure 42: Children with Zero Dose .............................................................................................................................. 48 Figure 43: No Permission for Vaccination ..................................................................................................................... 48 Figure 44: Information about Working of LHWs ............................................................................................................ 48 Figure 45: Preferred Channels of Communication for Vaccination Messages ............................................................... 49 Figure 46: Housing Structures in Slums and Underserved Areas .................................................................................. 50 Figure 47: Fully Immunized Children Vs. Children with Zero Dose of Mothers with No Formal Education ..................... 51 Figure 48: Fully Immunized Children Vs. Children with Zero Dose living in Kacha Housing Structures ......................... 51 Figure 49: Fully Immunized Children Vs. Children with Zero Dose in Houses without Toilet Facilities ........................... 51 Figure 50: Fully Immunized Children vs. Children with Zero Dose of Families Working on Daily Wages ....................... 52 Figure 51: Fully Immunized Children Vs. Children with Zero Dose of Families Who Had Debt Burden.......................... 52

List of Acronyms BCG Bacillus Calmette–Guérin

CBV Community Based Vaccinator

CHIP Civil Society Human and Institutional Development Programme

CI Confidence Interval

CNIC Computerized National Identity Card

CSO Civil Society Organization

DEFF Design Effect Factor

EPI Expanded Program on Immunization

ESS Effective Sample Size

GDP Gross Domestic Product

Hep B Hepatitis B

ILR Ice Lined Refrigerator

LHV Lady Health Visitor

LHW Lady Health Worker

MCH Maternal and Child Health Care

MNCH Maternal, Neonatal and Child Health

OPV Oral Polio Vaccine

PCV Pneumococcal Conjugate Vaccine

PKR Pakistani Rupee

PHS Punjab Health Survey

SOP Standard Operating Procedure

SPSS Statistical Package for the Social Sciences

STATA Statistics and Data

UN United Nations

UC Union Council

UNDP United Nations Development Programme

UN-Habitat United Nations Human Settlement Programme

UNICEF United Nations Children's Fund

WASH Water, Sanitation and Hygiene

WHO World Health Organization

WMC Waste Management Company

1

Executive Summary

An in-depth profiling of slums/underserved areas located within the five largest cities of Punjab province in Pakistan i.e. Faisalabad, Rawalpindi, Lahore, Multan and Gujranwala has been undertaken between 2018-2019, with the following objectives i.e. to collect the socio-demographic information of the residents of slums and underserved areas, to assess the fixed EPI centers, to compile the data of health and EPI recourses at the union councils level and to determine the childhood immunization coverage rates in the slums and underserved areas. There are 25 towns and 453 union councils in these five cities. Slums/underserved areas (2164) are found in 100 percent towns of 77 percent union councils (351 out of 453). Almost 19 percent of the total slums are without any legal evidence of their registration status. The five cities have a total population of 20.39 million; the proportion of population living in slums/underserved areas is 46 percent (9.35 million out of 20.39). Vaccination card retention is found among only 61 percent of the children (55 percent boys vs 45 percent girls). Overall, 63 percent children are fully immunized and 20 percent are partially vaccinated (records and recall). Almost 17 percent children are zero dose. Almost 35 percent union councils do not have public healthcare facilities and 32 percent UCs do not have fixed EPI centers. Similarly, 32 percent UCs where no fixed EPI centers. Almost 61 percent of slums/underserved areas report that LHWs do not visit their areas. Almost half of the houses (47 percent) in slums and 13 percent in underserved areas are Kacha-Pacca (mixed). Assessment of water and sanitation conditions indicates that access of slums/underserved areas to government water supply is weak (70 percent). The most prevalent source of water is ground water. In terms of sanitation, 1 percent slums/underserved areas do not have toilet facilities and therefore practice open defecation. The houses, which have toilet facilities, little less than half of them, are open pit/traditional toilets (47 percent). Further analysis on the status of drainage system shows that majority of the areas have either filthy or choked drains (46 percent), or drains are absent altogether (33 percent). This report finds that living conditions of slum dwellers and underserved areas are not only poor, but major disparities also exist in terms of their accessibility to health and EPI centers. It is important to improve the access and demand of health and EPI services so that children and women can be protected from vaccine preventable diseases.

Box 1 Key Highlights Childhood Immunization

1. 37% children living in slums/underserved areas are unimmunized or under immunized

Health Facilities 2. 35% UCs do not have public healthcare

facilities where 507 slums/underserved areas are located

3. Lady Health Workers (LHWs) are not found in 61% slums/underserved areas.

Infrastructure 4. 47% houses of slums/underserved areas are

Kacha-Pacca. 5. 19% slums do not possess documents to prove

their registration status. WASH Facilities

6. 70% slums/underserved areas do not have government water supply system.

7. 47% slums/underserved areas have traditional or open pit toilet.

8. 33% slums/underserved areas do not have paved drains.

Education Facilities 9. 23% slums/underserved areas do not have

schools.

2

Chapter 1 Introduction

3

Chapter 1: Introduction

1.1 Introduction Pakistan is the 5th most populous country of the world with the current estimated population of 212,235,0301. According to the United Nations (UN) population estimation, the population of Pakistan will reach up to 242,234,000 by 20252. The increase in population is more observable in the major cities of Pakistan where migration from rural to urban areas is principally more-than-proportionate, leading to the development of unplanned settlements in and around cities, identified as “slums”. The United Nations Human Settlements Programme (UN-Habitat) defines “slums” as informal settlements with high population density, poor living conditions and weak infrastructural provisions (United Nations, 2016)3. According to the estimation of UN for 2014, the slum population was 32,265,000 in urban areas of Pakistan4. Currently, 36.9 percent of the total population of Pakistan makes up the urban population, which is expected to increase to 50.2 percent by 20505. The urban population is growing at the rate of 3 percent annually (Sheikh & Nabi, 2017). It is expected that the cities of Pakistan will accommodate 250 million people by the year 20306. Considering the growth rate of urban population of present day, the slum population is likely to increase even further by 2030 in absence of proper urban planning78. According to existing studies on slum development, people move from rural to urban areas in search of better economic opportunities. Since Punjab is contributing the most to the national Gross Domestic Product (GDP) and is the largest economic hub in Pakistan, the rate of urbanization has been highest in this province9. Punjab or the ‘land of five waters’ is the most industrialized province of the country making up to 24 percent of the GDP of the province. Consisting of major transnational region, the province is bordered by the other three provinces i.e. Balochistan, Sindh and Khyber Pakhtunkhwa of Pakistan, making movement from all other provinces easier to the province. Punjab is known for its comparative prosperity and the lowest rate of poverty among all other provinces of Pakistan. However, there is a clear divide in the Southern and Northern parts of Punjab with poverty line being lowest in the North of the province when compared to the South. As per global statistics, Punjab is South Asia’s most urbanized region with as many as 40 percent people residing in its urban areas. According to World Bank, the urbanization in Pakistan is ‘hidden and messy’10. The problems associated with this hidden and messy urbanization include poor housing quality and affordability, water and sanitation, health, education and transportation. According to existing studies, these problems are most observable in the five cities of Punjab i.e. Faisalabad, Gujranwala, Lahore, Rawalpindi and Multan. Between 1998 to 2017, these five cities have seen a population growth with following increase i.e. Lahore (116.32 percent increase in population), Faisalabad (59.49 percent increase in population), Rawalpindi (48.84 percent increase in population), Gujranwala (78.10 percent increase in population), Multan (56.33 percent increase in population)11. Considering the population growth of urban Punjab and the haphazard growth of cities, it is essential to elaborate the inequities in detail.

1.1.1 Demography According to the latest Pakistan Economic Survey (2018-19), Punjab is the most populous province of Pakistan and accounts for 110,012,000 of population for the year 201712. The second largest city of Pakistan and the capital of Punjab, Lahore has roughly 30 percent of its settlements as slums

1 World Bank. (2019). Population Total. Retrieved from https://data.worldbank.org/indicator/SP.POP.TOTL?locations=PK 2 United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, custom data acquired via website. 3 Habitat, United Nations. 2016. Housing & slum upgrading. Retrieved from http://unhabitat.org/urban-themes/housing-slum-upgrading/) 4 UNMDGs. (2019). Retrieved from mdgs.un.org 5 United Nations, Department of Economic and Social Affairs, Population Division (2018). World Urbanization Prospects: The 2018 Revision. 6 Sheikh, H., & Nabi, I. (2017). The six biggest challenges facing Pakistan’s urban future. Pakistan’s Growth Story. Retrieved from https://pakistangrowthstory.org/2017/01/10/6-challenges-facing-pakistans-urban-future/ 7 Ibid. 8 Buque, Mindra & Duncan, T. (2016). Immunization, urbanization and slums: A review of evidence. UNICEF. 9 Sheikh, H., & Nabi, I. (2017). The six biggest challenges facing Pakistan’s urban future. Pakistan’s Growth Story. Retrieved from https://pakistangrowthstory.org/2017/01/10/6-challenges-facing-pakistans-urban-future/ 10 Centre, I. (2019). The six biggest challenges facing Pakistan's urban future - IGC. [online] IGC. Available at: https://www.theigc.org/blog/the-six-biggest-challenges-facing-pakistans-urban-future/ [Accessed 30 Nov. 2019]. 11 Portrait of Change in Punjab (Translating Evidence from the Census 2017). Punjab Economic Research Institute (PERI). Available at: https://peri.punjab.gov.pk/system/files/Policy%20Brief%20August%202017.pdf 12 Pakistan Economic Survey 2018-19, Ministry of Finance, Government of Pakistan. Retrieved from: http://finance.gov.pk/survey/chapters_19/Economic_Survey_2018_19.pdf

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(Abubakar, 2016)13. The slums of Lahore are home to an estimated population of 1.7 million people (UN-HABITATIII, 2015). The proportion of urban slum population in Lahore has reached the upper limit threshold of the city’s total population. It has a population density of 400 persons/sq km (UN-HABITATIII, 2015). In case of slums of Faisalabad, the number of slum-dwelling units ranges from 42 to 2851 (Ahmed, Mustafa & Khan, 2015)14.

1.1.2 Number of Slums According to the estimations of UN HABITAT III (2015), Lahore has approximately 308 informal settlements or slums (National Report of Pakistan for HABITAT III, 2015)15. Faisalabad ranks as the third most populous city of Pakistan and is home to 104 slums (Ahmed, Mustafa & Khan, 2015)16.

1.1.3 Situation of Health in Slums A study on “Health Status and Hygiene Practices in Slums: A Case Study of Lahore Pakistan” identifies that about 9.2 percent respondents of the survey have unhealthy family members at the time of the survey. Most of the slum dwellers (60 percent) have gastrointestinal tract related problems17. Other sicknesses caused by water borne diseases are higher when compared to Bangladesh and India. The contributing factors to high disease occurrence include low quality drinking water, poor hygiene and sanitation practices and open sewerage system. The dengue occurrence for slums in Lahore is lower in 2014, when compared to 2011. Health units are accessible to only 57.2 percent of the residents, which is another cause of poor healthcare availability in slums of Lahore. Likewise, an analysis on slums of Faisalabad reveals that diseases like diphtheria, tuberculosis, tetanus, measles and prosthesis, are common in slums of Faisalabad taken in the sample size of 213 slum dwellers (Ahmed, Mustafa & Khan, 2015)18. An alternate study on the “socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: A case study of Arifwala Pakistan” indicates that 91.75 percent of the sample population of the area do not adopt any precautionary measures against dengue. Similarly, only 25 percent people of the area are satisfied by the role of Lady Health Workers (LHWs) in their area. Infant mortality rate of the region is 57 percent; whereas, 2.84 percent of the adult population is suffering from diseases like Asthma, lungs, liver or kidney diseases.19

1.1.4 Status of Immunization in Slums A study conducted on 104 slums of Faisalabad indicates that 84 percent of the children are vaccinated and have received any dose of vaccine; whereas, 3.3 percent of the children are not vaccinated. On the other hand, 12 percent of the respondents are without any knowledge of vaccination. Another study conducted on the slums of Bahawalpur reveals that out of the 306 children surveyed, only 26 percent have a vaccination card. The highest coverage is for BCG+PV0 vaccine. First dose against Measles is received by as many as 84 percent of the children; whereas, second dose is received by only 42 percent of the children. 59.2 percent mothers of the children who have completed their vaccination schedule are educated over intermediate level.20 The respondents of the survey in Arifwala contend that 100 percent of the children are secured against polio; whereas, 99 percent are secured against diseases caused by missing out on a vaccine.21

13 Abubakar, M. (2016). Women and slums. Retrieved 21 September 2019, from http://www.lead.org.pk/lead/postDetail.aspx?postid=326 14 Ibid. 15 National Report of Pakistan for HABITAT III. (2015). Islamabad. 16 Ahmed, R., Mustafa, U., & Khan, A. (2015). Socio-economic Status of Transferred and Non-transferred Urban Slums: A Case Study from Faisalabad. The Pakistan Development Review, 54(4I-II), 947-962. doi: 10.30541/v54i4i-iipp.947-962 17 Ghafoor, Gul & Qureshi, Ahmed & Ghafoor, Naghmana & Shehzad, Laila. (2014). Health Status and Hygiene Practices in Slums: A Case Study of Lahore, Pakistan. Biologia (Lahore, Pakistan). 273-278. 18 Ibid. 19 Faheem, M., Mehmood, B., & Shah (2016), M. N. Exploration of socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: a case study of Arifwala Pakistan. 20 Badar, S., Qadri, S., (2016). Childhood Immunization in Slums of Bahawalpur City. Journal of University Medical and Dental College. 7 (2). 35-40. 21 Faheem, M., Mehmood, B., & Shah (2016), M. N. Exploration of socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: a case study of Arifwala Pakistan.

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1.1.5 Other Inequities 1.1.5.1 Housing Infrastructure The study on “Health Status and Hygiene Practices in Slums: A Case Study of Lahore Pakistan” indicates that majority of the households have between 5-10 people residing in them. On the other hand, as per the study conducted on slums of Arifwala, there are 10 people living per square foot of space.22 23 88.7 percent of the households are with their own electricity meter; whereas, 1.7 percent households use their meter through a wire which is connected to some other meter present within the vicinity. The study further shows a weak relationship between housing infrastructure and health; which means that with the improvement in the housing infrastructure, the health of the household will not necessarily improve24.

1.1.5.2 Education As per the study on slums of Lahore, about half of the sample population (54.5 percent) have no primary education. On the contrary, 81 percent of mothers in Arifwala have education till matric. Educated mothers are more likely to vaccinate their children.25

1.1.5.3 Income A case study on health status and hygiene practices from Lahore slums reveal that slum dwellers earn their income through small occupations, via which most are able to earn only PKR 6000 a month26. The study also reveals a correlation between low earning and poor health due to less expenditure on health and well-being27.

For Arifwala, only 22.54 percent members are actively employed; whereas, 6.94 percent are looking for a job, 29 percent are engaged with domestic work and 40 percent are students. Unemployment rate is as high as 23.12 percent in the area.28

1.1.5.4 Water and Sanitation The case study on Lahore slums indicates that the surveyed slum-dwellers are receiving unsafe drinking water in terms of smell, taste and presence of particles. These factors are leading to poor health of slum-dwellers.

96 percent of the households in slums of Lahore have toilet facilities; where underground sewerage system is available to 52 percent of the respondents. Rest of the respondents report the presence of open sewerage; which is responsible for spread of Malaria in the region, as per the study29. For Arifwala, only 12.4 percent of the houses have Pacca/concrete sewerage system; whereas, 28.2 percent of houses have Kacha and 59.5 percent of the households are with mixed sewerage system. People in slums are drug addicts with drug abuse being reported to be very high at 32 percent; whereas, it is high in 46.7 percent of households30.

22 Ghafoor, Gul & Qureshi, Ahmed & Ghafoor, Naghmana & Shehzad, Laila. (2014). Health Status and Hygiene Practices in Slums: A Case Study of Lahore, Pakistan. Biologia (Lahore, Pakistan). 273-278. 23 Faheem, M., Mehmood, B., & Shah (2016), m. N. Exploration of socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: a case study of Arifwala Pakistan. 24 Faheem, m., mehmood, b., & shah (2016), m. N. Exploration of socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: a case study of Arifwala Pakistan. 25 Faheem, m., mehmood, b., & shah (2016), m. N. Exploration of socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: a case study of Arifwala Pakistan. 26 Ghafoor, Gul & Qureshi, Ahmed & Ghafoor, Naghmana & Shehzad, Laila. (2014). Health Status and Hygiene Practices in Slums: A Case Study of Lahore, Pakistan. Biologia (Lahore, Pakistan). 273-278. 27 Ghafoor, Gul & Qureshi, Ahmed & Ghafoor, Naghmana & Shehzad, Laila. (2014). Health Status and Hygiene Practices in Slums: A Case Study of Lahore, Pakistan. Biologia (Lahore, Pakistan). 273-278. 28 Faheem, m., mehmood, b., & shah (2016), m. N. Exploration of socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: a case study of Arifwala Pakistan. 29 Ghafoor, Gul & Qureshi, Ahmed & Ghafoor, Naghmana & Shehzad, Laila. (2014). Health Status and Hygiene Practices in Slums: A Case Study of Lahore, Pakistan. Biologia (Lahore, Pakistan). 273-278. 30 Faheem, m., mehmood, b., & shah (2016), m. N. Exploration of socio-economic problems of the inhabitants of slum areas and their impact on vicinity residents: a case study of Arifwala Pakistan.

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1.2 Initiatives for Slum-Dwellers by the Private Sector Private sector has undertaken some initiatives for the poor of urban slums in Punjab. The installation of solar water filtration plants in urban slums is initiated by Rotary, funded by Coca-Cola Pakistan through their implementing partner United Nations Development Programme (UNDP) under the Zindagi project with an objective to provide clean drinking water and mitigating the transmission of water-borne diseases in Pakistan. Installation is initiated in seven polio high risk areas including Jaranwala - Punjab, Muzaffargarh - Punjab, Renala Khurd - Punjab. These areas face lack of clean drinking water, no availability of formal health care services, poor sanitation and hygiene conditions. Another US $ 80,000 project is currently in its second phase where plants have been installed in Basti Rahim Baksh, Renala Khurd, and Okara District. It will benefit a total of 100,000 individuals including 20,000 women and 40,000 children31.

1.3 Objectives The general objective of this study was to prepare the in-depth profiling of slums and underserved areas located within the five largest cities of Punjab province in Pakistan. The specific objectives of this study were to: 1. To collect the socio-demographic information of the residents of slums and underserved areas 2. To assess the fixed EPI centers 3. To compile the data of health and EPI recourses at the union councils level 4. To determine the childhood immunization coverage rates in the slums and underserved areas

1.4 Rationale The review of literature on slums of Punjab reveals that the data on housing infrastructures, water and sanitation practices and immunization status of children in slum areas of Punjab is limited. Therefore, this study was designed and conducted for the following reasons:

There is no comprehensive report or tangible dataset available specifically for slums/underserved areas. The studies are carried out in one specific slum or a few sampled slums and are not a true representation of inequities prevalent in all slums. Moreover, existing studies rely on outdated or nationally non-representative datasets, bringing the validity of research in question;

Punjab is the most populous province of Pakistan and most popular for urban migration. Systematically collected scientific data on geographical scale, locations and population of slums in major cities is not only essential to inform policy-makers for needed interventions. ;

The available literature does not have comprehensive information about the scale and situation of slums/ underserved areas;

A comprehensive list and profile of slums is not available which would inform planners about the geographical scale, locations and population of slums;

Additionally, it is not clear whether people living in slums which are not considered legal/registered/regularized in the records of relevant public departments were included in the National Census or not. The current resource allocations and provision of public services is decided according to the available information hence do not cater slums which are not recognised officially;

No secondary dataset is available which provides a complete picture of the status of health and immunization practices in slums and underserved areas. Although some studies mention a few reasons for zero-dose and unimmunized children, an extensive approach on the pattern of coverage survey has not been adopted by any of the studies to understand the reasons for under-immunization. An extensive understanding of slum lifestyle and their socioeconomic conditions is to be undertaken to draft and implement better immunization-related policies;

Coverage surveys have never been undertaken in slums hence status of immunization was never known for realistic planning and resource allocation.

The micro plans of vaccinators and LHWs are prepared based on targets only and do not include specific coverage of slums. The comprehensive data on slums/underserved areas would help in setting up realistic targets for slums/underserved areas.

Action plans for improvement of vaccination and general health conditions in slums/underserved areas would become possible.

There is little or no data available on the role of private and not-for-profit sector on the kind of interventions undertaken by these sectors for the urban poor. The potential for these sectors to provide for the urban poor has not yet been explored.

31 New World: “Zindagi " Inclusive Sustainable Human Development Initiatives (3rd Generation)

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Chapter 2 Methodology

Dreams Never Come True!

Chamanabad is a registered slum, which was legalized in 2000 and

has around 3000 residents. Despite the legalization of the slum, the

residents are deprived of the basic necessities of life including

sanitation system and water supply by the government.

“Chamanabad has been my home since last 10 years and I know this

place a little too well. Ask me about the ‘humans of Chamanabad’, ‘the

history of this place’, ‘our famous Chai wala (tea-stall holder)’ and ‘Mai

Naseema of big Jhuggi’ (a slum dwelling)’. I will know it all”, said Sallu,

a 34 years old resident of Chamanabad, Union Council Chak Jalal Din,

city Rawalpindi.

Sallu is a daily wage construction worker in the nearby locality. Since

Sallu is the only breadwinner for his family and his daily wage is very

low, his household usually operates in financial debt.

“My wife talks about dreams! We both had them as individuals and now

we have them as a couple. We want our children to be educated so

that they can be empowered and can have a better life than ours. Alas!

Our poverty does not allow this as of yet”- Sallu explained further.

He talks about education. We do not even have a proper healthcare

system in this area.

“You have asked me about Lady Health Workers, I do not know who

they are and I do not really have any information about them.”- Clarifies

Naheeda.

Sallu’s wife Naheeda is a 30 years old woman without formal

education. Naheeda, unlike her husband, is a fan of few words:

“We have dreams, big dreams but we know that their translation into

reality is not possible in this life”- she shared in pure agony.

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Chapter 2: Methodology

This part describes the detailed methodology adopted for the profiling of slums / underserved areas. This methodology was designed in close consultation with the UNICEF Pakistan Country Office, UNICEF Pakistan Field Office in Lahore and Provincial Expanded Programme on Immunization (EPI) Cell, Punjab, Pakistan. The process was made participatory and engaging for having community driven perspectives. Triangulation, validation and supportive monitoring were adopted as the key principles and formed the backbone of the entire process. The methodology was finalized according to the security situation and local context.

2.1 Study Design

This was a cross-sectional study undertaken to prepare the in-depth profiling of slums / underserved areas. The following four key activities were conducted for the purpose of this study.

2.2 Study Sites

The study was conducted in the slums / underserved areas located within the five largest cities of Punjab province of Pakistan i.e. Faisalabad, Gujranwala, Lahore, Multan, and Rawalpindi. The administrative structure of Pakistan distributes the country into four provinces and Islamabad, Azad Kashmir and Gilgit Baltistan as federally administered areas. The provinces are further distributed into districts. Each district is distributed into multiple towns (tehsils), which are further distributed into union councils. Each union council has 5 to 15 villages/areas depending on the context and rural/urban settings in each province. Previously, the performance of the country used to be assessed either at the provincial level and or at the district level. Gradually it has been realised that the performance needs to be monitored at the administrative unit level, which is union council. Each union council has a union council office, which is headed by the Secretary. The Secretary gets certain resources for the development of villages/areas for that particular union council. The resources of each union council have direct correlations with the performance outputs of that particular union council.

2.3 Study Duration This study was conducted between 2018 and 2019 with multiple intervals.

2.4 Study Respondents For the purpose of this study, four key activities were conducted and each activity had different respondents.

Table 1: Respondents of the Study

Activities Study Respondents Study Instruments

In-depth profiling of slums and underserved areas

Residents of slums / underserved areas

A. Questionnaire for Group Discussion in Slums / Underserved Areas

Assess the fixed EPI centers In-charge of EPI centers B. Questionnaire for EPI Center Assessment

Compile the health and EPI recourses data at union council levels

District Health Officer, District EPI Coordinator and District Supervisor Vaccination or their nominees for providing official information on health and EPI resources

C. Questionnaire for District or Town Health Office

Determine the childhood immunization coverage rates

Mothers of the children aged between 12 and 23 months

D. Questionnaire for Household Coverage Survey

1. In-depth profiling of

slums and

underserved areas

4. Determine the

childhood

immunization

coverage rates

2. Assess the fixed EPI

centers

3. Compile the health

and EPI recourses

data

Figure 1: Key Activities in The Study

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2.5 Sampling Procedures and Sample Size Activities 1: In-depth profiling of slums and underserved areas Slums/underserved areas form a major portion of the largest cities’ population. Consolidated information about the names, addresses and population sizes of slum / underserved areas were not available for realistic planning and extension of the health and EPI services. In order to identify the locations and scale of slums/underserved areas, to know the approximate size of target population and to prepare basic characteristics of these location, their holistic profiles were prepared. Step 1: Desk Research: For the purpose of this activity, initially desk research were carried out by the study team. The purpose was to understand the different dynamics of the urban poor living in the five largest cities of Pakistan. These conditions were assessed by gathering the literature retrieved from search engines on internet, academic research journals, and policy papers on slums / underserved areas. Step 2: Verification of the Study Areas: As there was no data (i.e. listing) available on the slums / underserved areas located in the five largest cities of Punjab, the study team visited and physically verified these areas. Step 3: Interactive Group Discussions: Once these areas were verified and listed by the study team, the process of collecting socio-demographic information of the residents of slums and underserved areas were started through interactive group discussions. The study team conducted one group discussion from each union council located in the slums and underserved areas. Sampling Method: A convenience sampling method was used for the purpose of interactive group discussions among the residents of slums and underserved areas. This was done because of the following three key reasons:

A. There were no lists or records of the households. The lists of households prepared by Community Based Vaccinators (CBVs) did not differentiate between the slums and non-slums areas

B. The security situations and general hostility as well as unwillingness to share information rendered a simple random sampling nearly improbable

C. Considered to be close knit communities, slums represent wide information sharing networks. Therefore estimates by these informants were deemed to be close to accurate through cross-validation

Sample Size: One group discussion was conducted from each union council located with the slums and underserved areas in the five largest cities of Punjab. 3 to 5 respondents were selected based on inclusion and exclusion criteria for the interactive group discussions. Inclusion and Exclusion Criteria: Following criteria were designed and adopted for the purpose of identifying the respondents for these interactive group discussions.

Table 2: Inclusion and Exclusion Criteria

Inclusion Criteria Exclusion Criteria

A. Resident of either slum or underserved area which was to be profiled

A. Not the resident of either slum or underserved area which was to be profiled

B. Have been living there for more two years B. Have been living there for less than two years

C. Have knowledge about physical infrastructure and other facilities of that particular area

C. No knowledge about the physical infrastructure and other facilities available in the area

Activities 2: Assess the Fixed EPI Centers The overall objectives of the assessment of fixed EPI centers were to know the strengths and weaknesses of the service delivery system and to analyse correlations between coverage rates and strengths and weakness of the system. Step 1: Obtaining the list of fixed EPI centers: The study team obtained the list of all fixed EPI centers from the department of health authorities. Step 2: Assessment of fixed EPI centers: Once the lists were obtained, fixed EPI centers were physically visited by the study team for assessment.

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No sampling method was used for this activity. All listed fixed EPI centers (i.e. 228) were physically visited and assessed by the study team. Activities 3: Compile the health and EPI recourses data Step 1: Obtaining data of health and EPI resources: The data of health and EPI resources available at the union council’s level were collected from the department of health. The study team used ‘Questionnaire for District or Town Health Office’ for this purpose. Step 2: Triangulation of Data: This data was triangulated with the information collected from the residents of slums and underserved areas through interactive group discussions (activity 1). No sampling method was used and data on the key variables (section 2.6) were collected by the study team through study instrument. Activities 4: Determine the childhood immunization coverage rates through survey The coverage survey was conducted to determine the childhood immunization rates by the study team. This background information about the households and respondents were also collected [Figure 2]. The correlations of these broader categories i.e. i). vaccination coverage in children, ii). characteristics of the mothers, and iii). vaccination coverage of the children were undertaken to comprehend the real reasons of high / low or no coverage rates in the slums and underserved areas. Step 1: Sampling Methodology: This was conducted according to the methodology of World Health Organization (WHO). The following six points were utilized in calculating the sample size for this coverage survey. 1. Penta 3 coverage rates from 3rd party sources 2. Effective Sample Size (ESS) 3. Design Effect Factor (DEFF) 4. Estimation of number of children aged between 12 and 23 months 5. Calculation of inflation or no response 6. Steps for determining sample size and cluster 1. Penta 3 Coverage Rates: The city was taken as an independent stratum and Punjab Health Survey (PHS) II 2017 report was utilized for using Penta 3 coverage rates. 2. Calculation of Effective Sample Size: ESS was determined through expected coverage and desired precision level was set at 95 percent Confidence Interval (CI) as per Table B - 1, Page 118, WHO reference manual. 3. Design Effect Factor: Post measles campaign design effect factor 2.7 calculated for the 3rd party survey 2018 was utilized as a basis for calculating the sample size.

A. Vaccination Coverage in Children

A1. Vaccination Cards

A2. Fully Immunized

A3. Antigen wise Coverage

A4. Zero Dose

A5. Reasons of Zero Dose

A6. Prefered Channels of Communication

B. Characteristics of Mothers

B1. Age

B2. Educational Levels

B3. Employment

C. Characteristics of Households

C1. Language

C2. Housing Structures

C3. Access to Water

C4. Access to Toilets

C5. Primary Occupations

Figure 2: Key Elements for Background Information of Respondents & Households

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4. Estimation of Number of Children Aged between 12 and 23 Months: The number of children aged between 12 and 23 months were determined by using the 3.5 percent of the total population are children between 0 and 1 year and 3.5 percent are between 1 and 2 years. The estimation of the number of 12-23 months old children was calculated as follows:

= Percentage of 12 – 23 months children in 100 household = 100 / 3 / 6.5 = 5 = This means that from every 5th to 6th house one child will be available = If the required # of children were not available in a cluster, new clusters were included and existing cluster was stopped.

5. Calculation of Inflation or No Response: Inflation or No Response factor from households was calculated by using the following formula mentioned in WHO manual. This factor is usually intended to include additional houses in case a child is not available at a set interval or has refused to participate. In order to overcome this, additional houses were also listed and profiled. The inflation or no-response factor was calculated as follows: No Response = 100 / 100 – P (Household Did not Respond)

= 100 / 100-5 = 1.05

6. Calculation of Sample Size and Clusters: Calculation of sample size was done once the DEFF and ESS, including No Response Inflation factor were all set. The following steps were undertaken to ascertain the sample-size: Total Completed Interviews = # of strata X ESS target from table B of WHO guidelines X DEFF32 Total Households to be visited to get the Target # of Households to be interviewed = ESS X DEFF X household to find a child X no response inflation factor Number of Households to Visit per Strata = ESS X DEFF X household to find a child X no response inflation factor Number of Clusters = ESS X DEFF / Household to be interviewed per cluster Total Households to Visit per Cluster = Household to find a child X no response inflation factor X household to be interviewed per cluster. Step 2: Sampling Procedure: The slum was taken as a cluster. The following steps were undertaken during survey taking: 1. The city-wise lists of slums located in all urban towns were organized in an ascending order on the

basis of population 2. The random number for selecting slum was calculated by dividing the total slums by total clusters 3. After knowing the random number e.g. 2 or 3 or 4 or 5, every 2nd-5th slum of each town was picked

up for mapping and listing 4. Maps were prepared for each selected slum (cluster). The buildings including government schools

were numbered and marked. Maps of the areas/clusters/slums were prepared and residential buildings were marked for the listing of the households

5. Then by throwing a pencil on the map, the residential block was selected randomly 6. The selected block was listed and number of children were also listed 7. A list of minimum 80 to 150 houses was prepared

32 Taken from Post Measles Campaign Analysis by WHO

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8. The total listed households were divided by 15 to calculate the random number for selecting a household for checking availability of children

9. Listed households with the final random number were picked for interview In case of unavailability of 15 children in a cluster, additional clusters were added

2.6 Key Variables Table 3: Key Variables In The Study

Activities Key Variables

In-depth profiling of slums and

underserved areas

1. Slums and Underserved Areas

2. Demography

3. Health and EPI Resources

4. Infrastructure

5. Social Welfare Services

Assess the fixed EPI centers 1. Infrastructures

2. System

3. Management and Facilities

4. Equipment and Supplies

5. Waste Management

6. Human Resources

Compile the health and EPI recourses

data

1. Administrative Layout

2. Healthcare Facilities

3. Equipment and Supplies

4. Human Resources

5. Nutrition Services

Determine the childhood immunization

coverage rates

1. Vaccination Coverage

2. Characteristics of the Mothers

3. Characteristics of the Households

4. Characteristics of Fully Immunized Vs. Zero Dose Children

2.7 Data Collection Instruments The data collection instruments were designed by the senior investigators and finalized in consultation with the UNICEF Pakistan officials. The instruments were pre-tested in order to ensure the consistency, appropriateness of language and sequencing of the questions. Based on the feedback from the pre-testing, the instruments were modified and rephrased, where necessary. These data collection instruments were not only translated into local languages but also culturally adopted, where necessary. All study instruments are attached in annexures.

2.8 Operational Definitions The operational definitions were defined based on the desk reviews as well as discussions with the health authorities i.e. Provincial EPI and District Department of Health.

2.8.1 Slums The definition of slums was reviewed from UN Habitat, Kachi Abadi Cell, Town Municipal Offices and Offices of Development Authority. Slums are a contiguous settlement where the inhabitants are characterized as having inadequate housing and basic services. A slum is often not recognized and addressed by the public authorities as an integral or equal part of the city. According to UN Habitat, the generic definition of a slum suggests that it is: ...a contiguous settlement where the inhabitants are characterized as having inadequate housing and basic services. A slum is often not recognized and addressed by the public authorities as an integral or equal part of the city (UN Habitat, 2010, p. 1333). Similarly, a slum household is defined as a group of individuals who live under the same roof that lacks one or more34 of the following conditions:

Limited access to improved water and sanitation

Weak housing structures

Insufficient living area

33 UN Habitat (2010), The Challenge of Slums: Global Report on Human Settlements 2003 34 This definition may be locally adapted for where some factors may be similar between the slums and majority of the society (UN Habitat).

13

Uncertain about legal ownership of the residential area

2.8.2 Peri-Urban Slums Slums located at the periphery of urban areas that join the borders of cities and rural areas.

2.8.3 Legal Status Concerned government department recognizes slums as either registered or regularized officially. Documentary evidence such as electricity bill or Computerized National Identity Card (CNIC) shows the address.

2.8.4 Underserved Areas Underserved Areas includes both planned residential areas with majority of the plastered housing structures. Underserved areas have one or more of the following conditions:

Low immunisation coverage or

High number of refusal 2.8.5 Expanded Programme on Immunization Expanded Programme on Immunization of the government of Pakistan for children and women of child-bearing age.

2.8.6 Outreach Vaccination Within remote and inaccessible areas where EPI or healthcare facilities have difficult access or do not exist, an outreach vaccinator covers the area through house to house visits

2.8.7 Ice Lined Refrigerators Ice Lined Refrigerator (ILR) for maintaining a particular temperature required for storage of vaccines.

2.8.8 Kacha Housing Structure All walls and ceilings are made of mud, straws, bamboos or material other than cement, concrete and iron and are vulnerable to damage due to excessive rains, floods or earthquake etc.

2.8.9 Pacca Housing Structure All walls and ceilings are made of cement, concrete and iron.

2.8.10 Kacha-Pacca Housing Structure Walls are made of concrete and iron while ceiling is made of mud, straw or bamboo or vice versa.

2.8.11 Antigen A liquid medicine, which develops immunity in the body of an individual.

2.8.12 Fully Immunized Children aged between 12 and 23 months who have completed vaccination of all doses starting from BCG-OPV0, Penta 1, Penta 2, Penta 3, and Measles-1. Children aged between 12 and 23 months who have completed vaccination of all doses starting from BCG-OPV0, Penta 1, Penta 2, Penta 3, and Measles-1.

2.8.13 Partially Vaccinated Children aged between 12 and 23 months who have received some doses of vaccination but could not complete it according to age wise requirements.

2.8.14 Dropout Any child aged between 12 and 23 months who has received BCG+OPV0 and Penta 1 and Penta 2 but did not receive Penta 3 or Measles-1.

14

2.8.15 Zero Dose Children aged between 12 and 23 months who have not received any doses of vaccines including polio, which may protect children from vaccine preventable diseases.

2.8.16 Records Under two years of children whose vaccination cards containing record of their age wise doses administered are available in readable condition for any confirmation.

2.8.17 Recall Under two years of children whose record of vaccination is not presented on any paper or card at the time of the survey and mother shares the vaccination status based on her memory or recall.

2.8.18 Vaccine Preventable Diseases The vaccine preventable diseases for children aged between 0 and 23 months are prevented through offering basic vaccination. The names of these diseases are Childhood Tuberculosis, Poliomyelitis, Rotavirus Diarrhea, Pneumonia, Diphtheria, Pertussis (Whooping Cough), Tetanus, Hepatitis B (Hep B), Haemophilus Influenza type b (Hib) and Measles.

2.8.19 Antigens as part of Basic Vaccine The following antigens are administered to children aged between 0 and 15 months old with different age intervals:

Table 4: Vaccination schedule

1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose 6th Dose

Immediately After Birth

6 Weeks 10 Weeks 14 Weeks 9 Months 15 Months

BCG+OPV0 OPV 1, Rota 1, Pneumococcal Conjugate Vaccine (PCV) 1, Penta 1

OPV 2, Rota 2, PCV 2, Penta 2

OPV 3, Rota 3, PCV 3, Penta 3

Measles-1 Measles-2

2.9 Data Analysis Techniques Systematic approach was adopted for cleaning, and verification and further entering of data in excel sheets as per the variables defined for this study. The data was analyzed by the Data Manager in Statistical Package for Social Sciences (SPSS) and Statistics and Data (STATA). The processed data is interpreted through tabular and graphical presentation required for quantitative analysis. The data of slums was segraged in the following categories.

Table 5: Categories of slums data

Categories Size Housing Structure

Legal Status

Facilities Location

Category A More than 60 households

Mostly Kacha/mud made/Tented

Mostly illegal

No solid/liquid waste management system No government water supply

Mostly under the bridge, near river, railway station and any empty land within the city

Category B Less than 60 households

Mostly Kacha/mud made/Tented

Mostly Illegal

No solid/liquid waste management system No government water supply

Surrounded by big houses

Category C More than 60 households

Mostly Pacca/ Plastered

Mostly legal

Mostly garbage management system and drains exist

Mostly upgraded from slums or housing societies or extension of towns

Category D More than 100 households

Mostly un-plastered

Mostly legal

No solid/liquid waste management system No government water supply

Originally rural area but gradually became part of the city hence located at the periphery of the city

2.10 Monitoring Mechanism

For the purpose of this study, timely review and rigorous monitoring system was put in place to ensure there were no detractions. This included engagement of a full-time team dedicated to holding surveys and field visits, timely submission of data, physical verification and further cleaning process of the data, and assignment for each team member. The monitoring ensured the following:

Verification of data either through telephonic correspondence or physical on-field visits Supportive supervision and daily review of field performance

15

Trouble shooting in case of problems Review of survey forms to ensure that no information was missed or fake or contradictory

2.11 Study Team and Training

A three-tiered teams were engaged in in-depth profiling of slums and underserved areas, assessment of fixed EPI centers, compilation of health and EPI resources data of union councils and childhood vaccination coverage in slums / underserved areas. The first tier of team comprised of a team leader, survey supervisors and data collectors. The team leader provided overall guidelines and end-to-end management of the process, the supervisors extended supportive supervision and monitoring of the data collection and ensured quality standards while surveyors collected the data from the field through physical visits, group discussions and individual interviews. The 2nd tier of the team consisted of data validation, cleaning, entry and analysis. The 3rd tier of the team comprised report writers responsible for undertaking desk researches and interpreting the results in an effective manner.

The training of study teams was conducted by the professionals prior to commencing data collection activities that includes study objectives, basic concepts on healthcare and immunization services, data collection, ethical considerations as well as confidentiality. In addition, they were trained on data entry processes (i.e. validation and cleaning before their final consolidation).

Figure 3: Study team composition

1. Team Leader Supervisors

Data Collectors

Data Entry Operators

2. Data Validation Team

Data Assistant

3. Report Writer Data Analyst

Graphic Designer

16

Chapter 3 Profiling of Slums and Underserved Areas

17

Chapter 3: Profiling of Slums and Underserved Areas

This part presents the profile of slums / underserved areas located within the five largest cities of Punjab i.e. Faisalabad, Gujranwala, Lahore, Multan and Rawalpindi. These profiles are presented around the following five broader categories i.e. Slums / Underserved Areas, Demography, Health and EPI Resources, Infrastructure and Social Welfare Services.

Key Highlights

A total of 453 union councils located in five cities

19 percent of slums were not registered

42 percent slums and 58 percent underserved areas were located within 351 union councils

46 percent population lived in slums (35 percent) and underserved areas (65 percent)

35 percent of union councils did not have healthcare facilities

32 percent of union councils did not have any fixed EPI centers

61 percent slums and underserved areas were uncovered by LHWs

28 percent of slums and underserved areas did not report presence of dengue workers

91 percent of slums and underserved areas utilized / aware from 1122 emergency service

91 percent of slums and underserved areas were not aware from 1038 emergency service

5 percent slums and underserved areas had Kacha housing structures

26 percent slums and underserved areas had Kacha/Pacca housing structures

69 percent slums and underserved areas had Pacca housing structures

99 percent houses had toilet facilities but 47 percent had traditional/open pit toilet

30 percent slums and underserved areas used government water supply for domestic use

21 percent of slums and underserved areas had drains with running water

46 percent of slums and underserved areas had choked/filthy drains

33 percent of slums and underserved areas had no drains

49 percent of slums and underserved areas had government waste pick up facility available

25 percent of slums and underserved areas had no schools

97 percent of slums and underserved areas had no active civil society organizations

61 percent of slums and underserved areas had no presence of informal groups

47 percent of slums and underserved areas had no public welfare schemes

3.1 Slums and Underserved Areas

3.1.1 Union Councils with and without Slums / Underserved Areas The study areas i.e. Faisalabad, Rawalpindi, Lahore, Multan and Gujranwala were administratively distribute into 25 towns and 453 union councils. Almost 77 percent of union councils (351 out of 453) had 2164 slums / underserved areas. [Figure 4] shows the distribution of areas in each city.

3.1.2 Total Number of Slums / Underserved Areas Overall, there were 42 percent (899) slums and 58 percent (1265) underserved areas located within 351 union councils (out of 453) in five cities. The highest number of slums were found in Lahore i.e. 356, followed by Multan (216) and Faisalabad (169). A similar pattern was observed for underserved areas. Lahore had the highest number of underserved areas i.e. 637, followed by Faisalabad (297) and Gujranwala (165). The greater number of slums / underserved did not refer to the greater number of population size. The size of slums varied across each city. Therefore, these numbers need to be analyzed according to their population sizes. Table 6 shows the details of slums and underserved areas in study sites.

76% 73% 77% 72%91% 77%

24% 27% 23% 28%9% 23%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

UCs without Slums / Underserved Areas

UCs with Slums / Underserved Areas

Figure 4: Percentage of Union Councils with and without

Slums / Underserved Areas

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Table 6: Total Number Of Slums And Underserved Areas In Study Sites

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 169 36% 297 64% 466

Rawalpindi 76 55% 62 45% 138

Lahore 356 36% 637 64% 993

Multan 216 68% 104 33% 320

Gujranwala 82 33% 165 67% 247

Total 899 42% 1265 58% 2164

3.1.3 Timeline of Emergence of Slums Overall, the emergence of slums has been lowest before 1950s and after 1991. The highest growth of urban slums were seen between 1951 and 1990 (62 percent) at a similar pace for five cities during 1950-1990s. The highest growth of slums were found in Faisalabad (65 percent) followed by Lahore (63 percent). The lowest growth of slums were found in Gujranwala (59 percent). The lowest growth of slums after 1991 were seen in Lahore which dropped from 63 to only 16 percent. The growth of slums during 1951-1990 was possibly due to the industrial growth or decline in agricultural profits in Multan city. [Figure 5] shows the timeline of emergence of slums.

3.1.4 Legal Status of Slums Almost 19 percent of slums were not registered in the five cities. The highest percentage of unregistered slums were reported from Gujranwala i.e. 43 percent (35 out of 82) whereas lowest percentage was reported from Faisalabad i.e. 11 percent (18 out of 169). It is important to note that, ‘if the electricity bill or Computerised National Identity Card of the residents were found in the name of the assessed areas, it was considered registered or legal’. The registration status of slums determined the eligibility to have resource allocation for having public services such as health, education, water and sanitation etc. The variation in the status of registration reflects the regularization of slums across different cities. Since Faisalabad (11 percent), Multan (17 perc. t), Lahore (18 percent) and Rawalpindi (24 percent) have the lowest percentage of unregistered slums. It seems that the city government has had them regularized in their records easily as compared to the Gujranwala. The population residing in these unregistered slums was 411,485 which is 12 percent of a total population residing in slums of five cities of Punjab (3,292,278). [Figure 6] shows the percentage of unregistered slums AND Table 7 shows the total numbers of registered and unregistered slums located in five cities.

Table 7: Total Number Of Registered And Unregistered Slums In Study Sites

Study Sites Registered Slums Unregistered Slums Total Slums

Faisalabad 151 89% 18 11% 169

Rawalpindi 58 76% 18 24% 76

Lahore 293 82% 63 18% 356

Multan 180 83% 36 17% 216

Gujranwala 47 57% 35 43% 82

Total 729 81% 170 19% 899

IN FIVE CITIES Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

10%

20% 21%

15%

21%

17%

65% 61% 63% 60% 59% 61%

25%

19% 16%

25%

20%

21%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Before 1950 1951-1990 1991 onwards

11%

24%

18% 17%

43%

19%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 5: Timeline of Emergence of Slums

Figure 6: Percentage of Unregistered Slums in Study Areas

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3.2 Demography 3.2.1 Population There were approximately 9.35 million people living in the slums / underserved areas, which is about 46 percent of the total population (20.39 million) of five cities of Punjab, as per the data of Pakistan Bureau of Statistics (2017). The higher population share i.e. 65 percent lives in underserved areas compared to 35 percent in slums. Table 8 shows the details of slums and underserved areas population in the study sites. Although Faisalabad had 466 slums / underserved areas but its population (1.3 million) is less than Gujranwala (1.4 million) where only 247 slums / underserved areas are located.

Table 8: Total Population In Slums And Underserved Areas In Study Sites

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 459327 34% 881049 66% 1340376

Rawalpindi 532155 55% 434844 45% 966999

Lahore 1519936 33% 3130318 67% 4650254

Multan 491250 53% 432270 47% 923520

Gujranwala 289610 20% 1179940 80% 1469550

Total 3292278 35% 6058421 65% 9350699

Overall, in slums / underserved areas, the approximate population of children aged between 0 and 11 months are 0.3 million (3.5 percent of the total population with 92 percent survival rate) and children under five years of age are 1.5 million. The approximate population of women of child-bearing age is two million. The slums / underserved areas in Lahore have the highest percentage (50 percent) of children aged between 0 and 11 months and under five years of age whereas, Rawalpindi and Multan have the lowest percentage (10 percent each) of children aged between 0 and 11 months and under five years age. Table 9 shows the details of total population of children aged between 0 and 11 months.

Table 9: Total Population Of Children Aged Between 0 And 11 Months [(3.5% And 92% Survival)]

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 14790 34% 28370 66% 43160

Rawalpindi 17135 55% 14002 45% 31137

Lahore 48942 33% 100796 67% 149738

Multan 15818 53% 13919 47% 29737

Gujranwala 9325 20% 37994 80% 47319

Total 106011 35% 195081 65% 301093

Table 10: Total Population Of Children Under Five Years Of Age

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 78086 34% 149778 66% 227864

Rawalpindi 90466 55% 73923 45% 164389

Lahore 258389 33% 532154 67% 790543

Multan 83513 53% 73486 47% 156999

Gujranwala 49234 20% 200589 80% 249823

Total 559687 35% 1029932 65% 1589619

Table 11: Total Population Of Women Of Child-Bearing Age

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 101052 34% 193831 66% 294883

Rawalpindi 117074 6% 95666 45% 212740

Lahore 334386 3% 688670 67% 1023056

Multan 108075 5% 95099 47% 203174

Gujranwala 63714 20% 259587 80% 323301

Total 724301 35% 1332853 65% 2057154

3.2.2 Types of Residents Almost 87 percent residents of slums / underserved areas were living in their respective locations for more than two years (Table 12) - called permanent residents - while almost 13 percent were temporarily displaced (Table 13). Only 0.4 percent belonged to the other nationalities (Table 14). The highest proportion of the permanent settlers were residing in slums / underserved areas of Gujranwala (92 percent). However, the lowest proportion was residing in Rawalpindi (78 percent).

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Table 12: Total Population Of Permanent Residents Of Slums And Underserved Areas

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 68766 81% 131586 83% 82% (200352)

Rawalpindi 69149 76% 60066 81% 78% (129215)

Lahore 213394 87% 411531 89% 89% (624925)

Multan 91111 87% 63005 91% 89% (154116)

Gujranwala 54154 96% 170230 91% 92% (224384)

Total 496574 85% 836418 88% 87% (1332992)

Similarly, temporary displaced were found in slums / underserved areas of all cities. The highest proportion of temporary displaced in slums and underserved areas were found in Rawalpindi (19 percent) followed by Faisalabad (18 percent). The lowest percentage of temporary displaced in slums and underserved areas were found in Gujranwala (8 percent).

Table 13: Total Population Of Temporary Displaced

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 16,639 19% 27,639 17% 18%

Rawalpindi 18,295 20% 13,749 19% 19%

Lahore 31,918 13% 47,064 10% 11%

Multan 12,752 12% 6,064 9% 11%

Gujranwala 2,155 4% 16,178 9% 8%

Total 81,759 14% 110,694 12% 13%

Residents belonging to other nationalities (could be permanent or temporary) were found only in two cities i.e. Rawalpindi (2 percent) and Multan (1 percent) in slums / underserved areas. Overall percentage of other nationals residing in slums / underserved areas were only 0.4 percent.

Table 14: Total Population Of Residents Belonged To Other Nationalities

Study Sites Slum Areas Underserved Areas Overall

Faisalabad 0 0% 12 0% 0%

Rawalpindi 3,102 3% 300 0% 2%

Lahore 105 0% 1,527 0% 0%

Multan 707 1% 350 1% 1%

Gujranwala 0 0% 0 0% 0%

Total 3,914 1% 2,189 0% 0.4%

3.3 Health and Epi Resources 3.3.1 Healthcare Facilities Almost 35 percent of union councils did not have public healthcare facilities. Gujranwala had the highest percentage (70 percent) of union councils without healthcare facilities whereas, only 4 percent union councils of Lahore were without healthcare facilities. Table 15 shows the details of union councils with and without public healthcare facilities.

Table 15: Union Councils With And Without Public Healthcare Facilities

Study Sites With Public Healthcare Facilities

Without Public Healthcare Facilities

Overall

Faisalabad 52 46% 61 54% 100%

Rawalpindi 28 47% 32 53% 100%

Lahore 160 96% 6 4% 100%

Multan 34 68% 16 32% 100%

Gujranwala 19 30% 45 70% 100%

Total 293 65% 160 35% 100%

A small percentage of slums / underserved areas reported presence of public or private healthcare facilities within two kilometers from their respective areas. For example, 0.50 percent slums / underserved areas (nine slums and one underserved areas) reported the presence of public healthcare facilities and only 0.30 percent slums / underserved areas reported the presence of private healthcare facilities (two slums and four underserved areas). Around 1 percent slums of Faisalabad reported the presence of private healthcare facilities. Only one percent slums in Lahore, 2 percent slums in Multan and 3 percent slums in Rawalpindi reported the presence of public healthcare facilities while only 1 percent underserved areas of Gujranwala reported the presence of public healthcare facility.

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3.3.2 EPI Centers Almost 32 percent of union councils (145 out of 453) did not have any fixed EPI centers in all five cities. The percentage of union councils without any fixed EPI centers were higher in Gujranwala i.e. 72 percent (46 out of 64)) and Rawalpindi i.e. 52 percent (31 out of 60) and lower in Lahore i.e. 1 percent (1 out of 166).

These union councils without fixed EPI centers had 993 slums / underserved areas. It is interesting to note that only 7 percent (141 out of 2164) of slums / underserved areas had reported the presence of fixed EPI centers with an easy access i.e. within two kilometers from their areas. The highest percentage of slums / underserved areas that mentioned the presence of fixed EPI centers with an easy access (i.e. within 2 kilometers) were reported in Lahore (8 percent) and Faisalabad (7 percent). Table 16 shows the details of union councils with and without EPI centers.

Table 16: Union councils with and without EPI centers

Study Sites With EPI Centers Without EPI Centers Total UCs

Faisalabad 62 55% 51 45% 113

Rawalpindi 29 48% 31 52% 60

Lahore 165 99% 1 1% 166

Multan 34 68% 16 32% 50

Gujranwala 18 28% 46 72% 64

Total 308 68% 145 32% 453

3.3.3 Outreach Vaccination Although 100 percent union councils had provision of outreach vaccination services as per the records provided by the department of health yet 29 percent of slums / underserved areas (22 percent in slums and 35 percent in underserved areas) reported non-provision of outreach vaccination services for their children and women [Table 17 shows the provision of outreach vaccination services in slums and underserved areas].

The highest percentage of slums / underserved areas of Gujranwala (69 percent), followed by Faisalabad (36 percent) reported non-provision of outreach vaccination services. A small percentage of slums / underserved areas of Multan (5 percent), followed by Rawalpindi (7 percent) reported non-provision of outreach vaccination services.

Table 17: Provision of outreach vaccination services in slums and underserved areas

Study Sites Provision in Slum Areas

Provision in Underserved Areas

Provision in Slums + Underserved

Areas

Total Slums + Underserved

Areas

Faisalabad 109 64% 189 64% 298 64% 466

Rawalpindi 72 95% 56 90% 128 93% 138

Lahore 296 83% 424 67% 720 73% 993

Multan 200 93% 104 100% 304 95% 320

Gujranwala 22 27% 55 33% 77 31% 247

Total 699 78% 828 65% 1527 71% 2164

IN FIVE CITIES Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

3.3.4 Health Workers

3.3.4.1 Lady Health Workers

LHWs were not found in 61 percent slums / underserved areas [Table 18]. More underserved areas were uncovered by the LHWs (62 percent) as compared to the slums (60 percent). Gujranwala (85 percent) and Faisalabad (78 percent) had the highest percentage of slums / underserved areas that were not covered by the LHWs whereas, Lahore had the lowest (45 percent) percentage of slums / underserved areas that were not covered by the LHWs.

Table 18: Percentage of uncovered areas in slums and underserved by LHWs

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 138 82% 225 76% 363 78%

Rawalpindi 43 57% 44 71% 87 63%

Lahore 134 38% 313 49% 447 45%

Multan 146 68% 65 63% 211 66%

Gujranwala 77 94% 133 81% 210 85%

Total 538 60% 780 62% 1318 61%

IN FIVE CITIES Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

*The percentage total is calculated by dividing the number of slums/underserved areas with LHWs to the total number of slums/underserved areas per city.

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3.3.4.2 Dengue Workers Overall, 28 percent of slums / underserved areas did not report presence of dengue workers in their respective areas. Almost 24 percent slums and 31 percent underserved areas did not have dengue workers present in them. Around 55 percent slums / underserved areas of Faisalabad and 45 percent slums / underserved areas of Gujranwala reported non presence of dengue workers whereas, all slums / underserved areas of Rawalpindi reported presence of dengue workers. A small percentage of slums / underserved areas of Multan (13 percent) reported non presence of dengue workers, followed by Lahore (13 percent). Table 19 shows the percentage of non-presence of dengue workers in slums and underserved areas.

Table 19: Percentage Of Non-Presence Of Dengue Workers In Slums And Underserved Areas

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 97 57% 161 54% 258 55%

Rawalpindi 0 0% 0 0% 0 0%

Lahore 87 24% 110 17% 197 20%

Multan 36 17% 7 7% 43 13%

Gujranwala 0 0% 112 68% 112 45%

Total 220 24% 390 31% 610 28%

In Five Cities Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

3.3.5 Emergency Health Services

3.3.5.1 Emergency Service by 1122

When asked, ‘do your area utilize the services of 1122 offered by the government to respond any domestic accidental emergency’? Majority of the residents of slums / underserved areas (91 percent) confirmed the utilization of emergency healthcare services by them, whenever needed. However, over 9 percent residents (13 percent from slums and 6 percent from underserved areas) reported that they were unaware of this service. Table 20 shows the percentage of residents of slums and underserved areas unaware of 1122 services being offered by Punjab Emergency Services, Government of Pakistan.

Table 20: Percentage of residents of slums and underserved areas unaware of 1122 services

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 13 8% 13 4% 26 6%

Rawalpindi 0 0% 0 0% 0 0%

Lahore 100 28% 52 8% 152 15%

Multan 3 1% 1 1% 4 1%

Gujranwala 0 0% 15 9% 15 6%

Total 116 13% 81 6% 197 9%

In Five Cities Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

3.3.5.2 Emergency Service by 1038 When asked, ‘do your area utilize services of 1038 offered by the government to respond emergency related situation of pregnant women’?, it was reported that almost 97 respondents (98 percent from slums and 96 percent from underserved areas) were not aware from the emergency services of 1038 offered by the government to respond emergency related situation of pregnant women. Table 21 shows the percentage of residents of slums and underserved areas unaware of 1038 services.

Table 21: Percentage of residents of slums and underserved areas unaware of 1038 services

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 163 96% 290 98% 453 97%

Rawalpindi 76 100% 62 100% 138 100%

Lahore 347 97% 596 94% 943 95%

Multan 215 100% 104 100% 319 100%

Gujranwala 82 100% 164 99% 246 99%

Total 883 98% 1216 96% 2099 97%

IN FIVE CITIES Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

Box 2: Emergency Service 1122

The Punjab Emergency Service (Rescue

1122) is the leading emergency

humanitarian service of Pakistan with

infrastructure in all 36 districts of Punjab

and is providing technical assistance to

other provinces.

SOURCE: Government of Pakistan

[http://www.rescue.gov.pk/]

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3.4 Infrastructure 3.4.1 Housing Structures Almost 12 percent houses in slum areas were Kacha/tented whereas, none of them in underserved areas were Kacha/tented. The highest percentage of Kacha/tented houses were found in slums of Gujranwala and Rawalpindi (15 percent each). [Figure 7] shows the percentage of Kacha / Tented housing structures in slums and underserved areas. Almost 47 percent houses in slums and 13 percent houses in underserved areas were Kacha Pacca. The highest percentage of Kacha Pacca houses were found in slums of Faisalabad (57 percent), followed by Lahore (52 percent) whereas in underserved areas, the highest percentage of Kacha Pacca houses were found in Rawalpindi (25 percent), followed by Gujranwala (24 percent). [Figure 8] shows the percentage of Kacha Pacca housing structures in slums and underserved areas. Almost 41 percent houses in slums and 87 percent houses in underserved areas were Pacca. The majority of underserved areas had Pacca housing structures. The highest percentage of Pacca housing structures were found in underserved areas of Lahore (95 percent), followed by Faisalabad (85 percent). The proportion of Pacca housing structures in slums were less than half of the total housing structures (41 percent). The lowest percentage of Pacca housing structures were found in slums of Faisalabad (34 percent) and Lahore (35 percent). [Figure 9] shows the percentage of Pacca housing structures in slums and underserved areas.

9%

15%13%

9%

15%12%

0% 0% 0% 0% 0% 0%

3%

8%5% 5% 3%

5%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Kacha Housing Structures in Slum Areas

Kacha Housing Structures in Underserved Areas

Overall

57%

33%

52%

42%

38%

47%

15%

25%

5%

21%

24%

13%

30%

30%

22%

33%

27%

26%

Faisalabad

Rawalpindi

Lahore

Multan

Gujranwala

Total

Kacha Pacca Housing Structures in Slum Areas

Kacha Pacca Housing Structures in Underserved Areas

Overall

34%

52%

35%

49%

47%

41%

85%

75%

95%

79%

76%

87%

67%

62%

74%

61%

70%

69%

Faisalabad

Rawalpindi

Lahore

Multan

Gujranwala

Total

Pacca Housing Structures in Slum Areas

Pacca Housing Structures in Underserved Areas

Overall

Figure 7: Percentage of Kacha (Tented) Housing Structures

in Slum and Underserved Areas

Figure 9: Percentage of Pacca Housing Structures in

Slum and Underserved Areas

Figure 8: Percentage of Kacha Pacca Housing Structures in

Slum and Underserved Areas

24

3.4.2 Toilet Facility in Households Although 99 percent houses had toilet facilities but almost half of them (47 percent) had traditional/open pit toilets. Traditional/open pit toilets were more common in underserved areas (50 percent) as compared to slums (43 percent). [Figure 10] shows the percentage of housing structures without toilet facilities. Underserved areas of Rawalpindi had the highest percentage of houses (64 percent) having traditional/open pit toilets whereas, lowest percentage was reported from Gujranwala (30 percent) in underserved areas. Same pattern was observed in slum areas where Rawalpindi had the highest percentage of houses (55 percent) having traditional/open pit toilets whereas, lowest percentage was reported from Gujranwala (36 percent) in slum areas. On an average, seven persons used single toilet facility in a day in slums and underserved areas. [Figure 11] shows the percentage of housing structures with traditional/open pit toilets in slums and underserved areas. Overall 53 percent houses’ toilets were connected with street drain (57 percent in slums and 50 percent in underserved areas). In underserved areas, highest percentage of toilets were connected with street drain reported from Gujranwala (70 percent) and lowest from Rawalpindi (36 percent). Same pattern was observed in slum areas (Gujranwala: 64 percent with highest and Rawalpindi: 45 percent with lowest). [Figure 12] shows the percentage of houses used street drain in slums and underserved areas.

In the absence of a toilet facility, residents of slums/underserved areas practiced open defecation. Almost 10 percent slums residents practiced open defecation compared to 3 percent in underserved areas.

2%1%

2%1% 1% 1%1%

0% 0%

6%

0%1%1%

0%1%

3%

1% 1%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slums Areas In Underserved Areas Total

45% 55%37% 48% 36% 43%

36%

64%58%

60%

30%50%

39%

59%

51%53%

32%

47%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slums Areas In Underserved Areas Total

55% 45% 63% 52% 64% 57%

64%36%

42%40%

70%50%

61%

41%49%

47%

68%

53%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slums Areas In Underserved Areas Total

Figure 10: Percentage of Housing Structures

Without Toilet Facilities

Figure 11: Percentage of Housing Structures with

Traditional / Open Pit Toilets

Figure 12: Type of Toilet - With Street Drain

25

3.4.3 Domestic Water Supply Overall, 23 percent slums and 36 percent underserved areas used government water supply for domestic use. Gujranwala had the lowest percentage of slums (9 percent) and underserved areas (14 percent) with government supply of water whereas, Lahore had the highest percentage of slums (31 percent) and underserved areas (43 percent) with the government water supply. [Figure 14] shows the percentage of residents used government water supply in slums and underserved areas. A higher percentage of slums were without government supply of water when compared to underserved areas. Almost half of the slums (55 percent) and little more than quarter of the underserved areas (34 percent) used ground water, which included tube wells, hand pumps, and or wells etc. [Figure 13] shows the percentage of residents used ground water in slums and underserved areas. Over 22 percent residents of slums and 31 percent residents of underserved areas had to rely on acquiring water from other sources for domestic consumption. [Figure 15] shows the percentage of residents who acquired water in slums and underserved areas from other sources.

3.4.4 Waste Management 3.4.4.1 For Liquid Waste It was reported that almost 21 percent (27 percent in slums and 17 percent in underserved areas) had drains with running water [Figure 16].

19%

59%

26%25%

17%

27%27%

37%

10%

21%15%

17%

24%

49%

16%

24%

16%21%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slum Areas In Underserved Areas Overall

17%

28% 32%

18%

9%

23%

30%

56%

43%

27%

14%

36%

25%

41% 39%

21%

12%

30%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slum Areas In Underserved Areas Overall

74%

50%

33%

73%67%

55%

15% 20%

41% 45%39%

34%36% 36% 38%

64%

48%43%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slum Areas In Underserved Areas Overall

9%

22%

36%

8%

24% 22%

55%

25%

16%

29%

47%

31%38%

22% 22%15%

40%

27%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slum Areas In Underserved Areas Overall

Figure 13: Percentage of Residents Used Ground

Water

Figure 14: Percentage of Residents Used

Government Water Supply

Figure 15: Percentage of Residents Used Other

Sources of Water

Figure 16: System for Waste Water Disposal:

Drains with Running Water

26

Overall, 33 percent (i.e. 27 percent slums and 38 percent underserved areas) areas did not have drains. Lahore had the highest percentage in underserved areas (52 percent) and Gujranwala had the highest percentage in slums areas (37 percent) without drains [Figure]. Little less than half (46 percent) of the slums/underserved areas had choked/filthy drains. The highest percentage of slums in Multan (56 percent) and Faisalabad (54 percent) had choked/filthy drains. In underserved areas, Faisalabad (57 percent) had the highest percentage, followed by Gujranwala (55 percent) and Rawalpindi (50 percent) where drains were choked/filthy [Figure ].

3.4.4.2 For Solid Waste

Almost 37 percent slums and 57 percent underserved areas had government waste pick up facility available [Figure 17]. A small percentage of slums (2 percent) and underserved areas (3 percent) had self-system for the disposal of their solid waste [Figure 18].

Overall, 61 percent slums and 40 percent underserved areas did not have waste pick up facility provided by the government. They threw their waste on empty plots or streets [Figure 19].

54%

26%

40%

56%

46%

46%

57%

50%

38%

43%

55%

46%

56%

37%

38%

52%

52%

46%

Faisalabad

Rawalpindi

Lahore

Multan

Gujranwala

Total

In Slum Areas In Underserved Areas Overall

27%

14%

34%

18%

37%

27%

16%

13%

52%

36%

30%

38%

20%

14%

46%

24%

32%

33%

Faisalabad

Rawalpindi

Lahore

Multan

Gujranwala

Total

In Slum Areas In Underserved Areas Overall

28%

34%

47%

37%

13%

37%

43%

66%

72%

53%

20%

57%

38%

49%

63%

42%

18%

49%

Faisalabad

Rawalpindi

Lahore

Multan

Gujranwala

Total

In Slum Areas In Underserved Areas Overall

4%

0%1% 1%

5%

2%

5%

3%2% 1%

8%

3%4%

1%2%

1%

7%

3%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

In Slum Areas In Underserved Areas Overall

68% 66% 52% 62% 82% 61%

52% 31%26%

46%

72%

40%

58%50%

35%

57%

75%

49%

Faisalabad Rawalpindi Lahore Multan Gujranwala TotalIn Slum Areas In Underserved Areas Overall

Figure 17: System for Waste Water Disposal: No Drains

Figure18: System for Waste Water Disposal: Chocked Drains

Figure 17: System for Solid Waste Disposal – Government

Figure 18: System for Solid Waste Disposal – Self

Figure 19: System for Solid Waste Disposal: Throwing on

Empty Plots / Streets

27

3.5 Social Welfare Services

3.5.1 Schools Although schools existed in majority of the slums / underserved areas but a significant number of slums (27 percent) and underserved areas (23 percent) had no schools. In slums, highest percentage was reported from Rawalpindi (41 percent) whereas in underserved areas, highest percentage was reported from Gujranwala (41 percent). Table 22 shows the percentage of slums and underserved areas without schools. It was reported that almost 73 percent of slums and 77 percent of underserved areas had schools i.e. access to primary education (overall 75 percent). However, type and quality of school education had not been assessed.

Table 22: Percentage of slums and underserved areas without the school facility

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 63 37% 76 26% 139 30%

Rawalpindi 31 41% 11 18% 42 30%

Lahore 80 22% 119 19% 199 20%

Multan 44 20% 18 17% 62 19%

Gujranwala 25 30% 67 41% 92 37%

Total 243 27% 291 23% 534 25%

In Five Cities Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

Overall availability of government schools were higher in slums (67 percent) as compared to the underserved areas (57 percent). Slums in Lahore (68 percent) and Multan (81 percent) had higher percentage of government schools when compared to their underserved areas (57 percent and 71 percent respectively). The slums / underserved areas had high percentage of private schools and Madrassas as well. Table 23 shows the percentage of slums and underserved areas with presence of government schools.

Table 23: Percentage of slums and underserved areas with presence of government schools

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 52% 51% 51%

Rawalpindi 60% 63% 61%

Lahore 68% 57% 60%

Multan 81% 71% 78%

Gujranwala 56% 54% 55%

Total 67% 57% 61%

3.5.2 Civil Society Organisations Almost 98 percent of the slums and 96 percent underserved areas did not have any active civil society organizations (CSOs). The slums of Gujranwala and Multan did not have any active CSO whereas, few were operational in the slums of Faisalabad, Lahore and Rawalpindi. Table 24 shows the percentage of slums and underserved areas with presence of civil society organizations. As for the types of services offered by CSOs, 0.6 percent (4) had health services in slums whereas, 2 percent (27) had education services in underserved areas.

Table 24: Percentage of slums and underserved areas with the presence of civil society organisations

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 2 1% 13 4% 15 3%

Rawalpindi 3 4% 1 2% 4 3%

Lahore 10 3% 28 4% 38 4%

Multan 0 0% 1 1% 1 0%

Gujranwala 0 0% 2 1% 2 1%

Total 15 2% 45 4% 60 3%

IN FIVE CITIES Total Slums: 899 Total Underserved Areas: 1265 Total Slums / Underserved Areas: 2164

3.5.3 Informal Groups A small percentage of slums (39 percent) and underserved areas (40 percent) had a presence of informal groups working in their respective areas. The highest percentage of informal groups were found in slums (57 percent) and underserved areas (63 percent) of Rawalpindi. The lowest percentage of informal groups were found in slums (32 percent) and underserved areas (22 percent) of Gujranwala. The majority of these informal groups were Masjid or Zakat committees and groups organized by the Priests. Table 25 shows the percentage of slums and underserved areas with presence of informal groups.

28

Table 25: Percentage of slums and underserved areas with the presence of informal groups

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 56 33% 117 39% 37%

Rawalpindi 43 57% 39 63% 59%

Lahore 138 39% 275 43% 42%

Multan 86 40% 33 32% 37%

Gujranwala 26 32% 36 22% 23%

Total 349 39% 500 40% 39%

3.5.4 Public Welfare Schemes Public welfare schemes were found in 39 percent slums and 63 percent underserved areas. In underserved areas, the highest percentage of public welfare schemes were found in Lahore (80 percent) and Gujranwala (59 percent) whereas lowest percentage were found in Rawalpindi (35 percent) and Multan (27 percent). The majority of these public welfare schemes included loan and stipend schemes, social benefit cards and vocational skills centers. Table 26 shows the percentage of slums and underserved areas with availability of public welfare schemes.

Table 26: Percentage Of Slums And Underserved Areas With The Availability Of Public Welfare Schemes

Study Sites In Slum Areas In Underserved Areas Overall

Faisalabad 56 33% 136 46% 41%

Rawalpindi 29 38% 22 35% 37%

Lahore 145 41% 512 80% 66%

Multan 80 37% 28 27% 34%

Gujranwala 40 49% 97 59% 55%

Total 350 39% 795 63% 53%

29

Chapter 4 Health and EPI Resources at Union Council

30

Chapter 4: Health and EPI Resources at Union Council of Punjab This part discuss the situation of health and EPI resources in all union councils located within the study areas. The data was obtained from the department of health authorities in each city. These are presented into five broader categories i.e. Administrative Layout, Healthcare Facilities, Equipment and Supplies, Human Resources and Nutrition Services. Key Highlights Overall in 453 union councils located within five cities:

77 percent UCs had slums and underserved areas 54 percent population lives in covered slums and underserved areas 35 percent UCs did not have public healthcare facilities 32 percent UCs did not have fixed EPI centers 375 healthcare facilities were located in 293 UCs 379 fixed EPI centers were located in 308 UCs 99 percent of fixed EPI centers had functional ILR 21 percent UCs were uncovered by the LHWs 100 percent UCs had dengue workers 524 vaccinators were deployed in 379 EPI centers

68 percent UCs delivered nutrition services

4.1 Administrative Layout 4.1.1 Number of Union Councils and Towns (Tehsils) in Study Areas Data regarding the total number of union councils and towns (tehsils) in all five cities were obtained. It showed that within the study areas i.e. five largest cities of Punjab, there were a total of 453 union councils located within the 25 towns (tehsils). Table 27 shows the detail information about the towns (tehsils) and union councils in study areas.

Table 27: Total Numbers Of Towns And Union Councils In Study Areas

Name of Cities No. of Towns (Tehsils) No. of Union Councils

Faisalabad 4 113

Rawalpindi 3 60

Lahore 10 166

Multan 4 50

Gujranwala 4 64

Total 25 453

4.1.2 Number of Union Councils that Housed Slums / Underserved Areas One of the important data regarding the union councils that housed slum areas (if located) were also obtained. The data showed that overall 77 percent of union councils (351 out of 453) had slums and underserved areas in all five cities. Table 28 shows the details of union councils that had slums / underserved areas in study areas.

Table 28: Total Number Of Union Councils That Housed Slum Areas

Name of Cities No. of Union Councils that had Slums / Underserved Areas

Total No. of Union Councils

Total No. of Towns (Tehsils)

Faisalabad 86 76% 113 4

Rawalpindi 44 73% 60 3

Lahore 127 77% 166 10

Multan 36 72% 50 4

Gujranwala 58 91% 64 4

Total 351 77% 453 25

4.1.3 Number and Population of UCs that Housed Slums / Underserved Areas Similarly, another important data regarding the population of each union council that housed slums / underserved areas were also obtained. The data showed that overall 54 percent population (9350699 out of 17342083) in 77 percent (351 out of 453) union councils housed slums and underserved areas.

31

Table 29 shows the details of population and union councils that had slums / underserved areas in each city.

Table 29: Total Population and Union Councils Housed by Slums and Underserved Areas

Name of Cities Population of UCs that housed slums / underserved areas

Total population in all UCs

UCs that housed slums / underserved areas

Total UCs

Faisalabad 1340376 46% 2908385 86 76% 113

Rawalpindi 966999 57% 1691919 44 73% 60

Lahore 4650254 49% 9429574 127 77% 166

Multan 923520 55% 1668441 36 72% 50

Gujranwala 1469550 89% 1643764 58 91% 64

Total 9350699 54% 17342083 351 77% 453

4.2 Healthcare Facilities 4.2.1 Union Councils with or without Healthcare Facilities Overall, 35 percent UCs (160 out of 453) did not have public healthcare facilities. Gujranwala (70 percent), Faisalabad (54 percent) and Rawalpindi (53 percent) had the highest percentage of UCs without any public healthcare facility. Only 4 percent UCs of Lahore and 32 percent UCs of Multan were without public healthcare facilities [Table 30]. Almost 35 percent of UCs without healthcare facilities, housed 507 slums / underserved areas. These slums / underserved areas were expected to access healthcare facilities located in UCs other than their own.

Table 30: Total Number Of Union Councils With And Without Healthcare Facilities

Study Sites Number of UCs with Healthcare Facilities

Number of UCs without Healthcare Facilities

Total UCs

Faisalabad 52 46% 61 54% 113

Rawalpindi 28 47% 32 53% 60

Lahore 160 96% 6 4% 166

Multan 34 68% 16 32% 50

Gujranwala 19 30% 45 70% 64

Total 293 65% 160 35% 453

4.2.2 Number of Healthcare Facilities Vs Union Councils Overall, there were 375 public healthcare facilities in five cities of Punjab. These 375 healthcare facilities were located in 293 UCs (out of 453 UCs). Among these 375 healthcare facilities, 280 were located in 223 UCs where 1657 slums/underserved areas were located. The highest number of public healthcare facilities were located into Lahore i.e. 217 (in 160 union councils) while the lowest in Gujranwala (i.e. 19 union councils) [Table 31].

Table 31: Total number of healthcare facilities vs union councils

Name of Cities Total UCs Total UCs with Healthcare Facilities No. of Healthcare Facilities

Faisalabad 113 52 52

Rawalpindi 60 28 32

Lahore 166 160 217

Multan 50 34 45

Gujranwala 64 19 29

Total 453 293 375

4.3 EPI Centers 4.3.1 Number of Fixed EPI Centers Vs Union Councils Overall, there were 379 fixed EPI centers located into 308 union councils (out of 453) [Table 32].

Table 32: Number Of Fixed EPI Centers In Union Councils

Study Sites UCs with EPI centers No. of EPI Centers

Faisalabad 62 67

Rawalpindi 29 29

Lahore 165 220

Multan 34 45

Gujranwala 18 18

Total 308 379

4.3.2 Union Councils with or without Fixed EPI Centers Overall, 32 percent (145 out of 453) UCs remained without fixed EPI centers [Table 33]. In Gujranwala, almost 72 percent (46 out of 64) of union councils did not have fixed EPI centers, followed by Rawalpindi

32

where almost 52 percent (31 out of 60) union councils did not have fixed EPI centers. Lahore was the only city where only 1 percent of union council (1 out of 166) were without fixed EPI centers.

Table 33: Number of union councils with or without fixed EPI centers

Study Sites UCs with EPI centers UCs without EPI centers Total UCs

Faisalabad 62 55% 51 45% 113

Rawalpindi 29 48% 31 52% 60

Lahore 165 99% 1 1% 166

Multan 34 68% 16 32% 50

Gujranwala 18 28% 46 72% 64

Total 308 68% 145 32% 453

4.3.3 Outreach Vaccination It was reported that overall, outreach vaccination services were made available in all (100 percent) union councils of all five cities. However, compare to this, 29 percent (22 percent in slums and 35 percent in underserved areas) of slums and underserved areas reported non-provision of outreach vaccination services [Section 3.3.3].

4.4 Equipment and Supplies 4.4.1 Availability of Functional Ice Lined Refrigerators (ILR) in EPI Centers The data regarding the availability of functional Ice Lined Refrigerators (ILR) in all 379 EPI centers located within the five cities were also obtained. It showed that almost all i.e. 99 percent (377 out of 379) EPI centers had functional ILR. [Table 34] shows the details of availability of functional ILR in all fixed EPI centers in five cities.

Table 34: Total Number of EPI Centers with Functional Ice Lined Refrigerators

Name of Cities

EPI Centers with Functional IRL

EPI Centers with Non-Functional IRL

Total EPI Centers

Faisalabad 67 100% 0 0% 67

Rawalpindi 27 93% 2 7% 29

Lahore 220 100% 0 0% 220

Multan 45 100% 0 0% 45

Gujranwala 18 100% 0 0% 18

Total 377 99% 2 1% 379

It is important to check the functionality of ILR together with the smooth power supply. Sometimes, frequent power break down may also disrupt the maintenance of cold chain.

4.5 Human Resources 4.5.1 Number of Active LHWs in Union Councils

Data regarding the LHWs currently active in the union councils were also obtained. It was reported that almost 21 percent of union councils (95 out of 453) were uncovered by the LHWs. [Table 35] shows the data of covered and uncovered areas by LHWs in all union councils of five cities.

Table 35: Total Number Of Union Councils Covered and Uncovered by LHWs

Name of Cities Total Union Councils Covered by LHWs

Total Union Councils Uncovered by LHW

Total No. of Union Councils

Faisalabad 69 61% 44 39% 113

Rawalpindi 29 48% 31 52% 60

Lahore 163 98% 3 2% 166

Multan 42 84% 8 16% 50

Gujranwala 55 86% 9 14% 64

Total 358 79% 95 21% 453

A total of 1972 LHWs were deployed in the union councils (358 out of 453) in five cities. [Table 36] shows number of LHWs deployed in union councils in five cities.

Table 36: Total Number of LHWs Deployed in Covered Areas

Name of Cities No. of LHWs Total UCs covered by LHWs

Faisalabad 173 69 61%

Rawalpindi 135 29 48%

Lahore 1335 163 98%

Multan 265 42 84%

Gujranwala 64 55 86%

Total 1972 358 79%

33

4.5.2 Availability and Number of Dengue Workers in Union Councils The data regarding the availability of dengue workers in all union councils (a total of 453) of five cities were also collected. It was reported that all union councils of five cities had dengue workers. Table 37 shows the total number of dengue workers in all union councils in five cities.

Table 37: Total Number of Dengue Workers in all Union Councils

Name of Cities No. of Active Dengue workers Total UCs in five cities

Faisalabad 113 113

Rawalpindi 60 60

Lahore 166 166

Multan 50 50

Gujranwala 64 64

Total 453 453

Comparison with the data collected through profiling of slums and underserved areas:

When compared the data of dengue workers collected by the study team from slums and underserved areas through profiling, it was observed that almost 28 percent (24 percent slums and 31 percent underserved areas) did not report the presence of dengue workers in their respective areas (Reference: Table 37).

The discrepancy calls for an urgent attention to streamline the outreach of dengue workers in the slums/underserved areas in an equitable manner.

4.5.3 Currently Active Vaccinators in Public Healthcare Facilities Data regarding the number and availability of vaccinators in all union councils of five cities were obtained. The deployment of number of vaccinators for each EPI center is determined by the type of healthcare facility where EPI section is housed or maintained as an independent EPI center. The secondary and tertiary level healthcare facilities have higher number of vaccinators as these are expected to cater a larger number of patients on a daily basis. It was reported that a total of 524 vaccinators were deployed in 379 EPI centers located in union councils of all five cities. [Table 38] shows the details of availability of vaccinators.

Table 38: Total Number of Active Vaccinators in all EPI Centers

Name of Cities

Total No. of Vaccinators

Total No. of EPI Centers

Faisalabad 75 67

Rawalpindi 29 29

Lahore 356 220

Multan 45 45

Gujranwala 19 18

Total 524 379

4.6 Nutrition Services 4.6.1 Delivery of Nutrition Services in Union Councils Data regarding the delivery of nutrition services in all union councils (453) of all five cities were obtained. It was reported that the nutrition services were being delivered in 68 percent of union councils (310 out of 453) in all five cities. However in the remaining union councils i.e. 32 percent (143 out of 453), nutrition services were not being offered. [Table 39] shows the details of nutrition services delivery in all union councils.

Table 39: Total Number Of Union Councils With Nutrition Service Deliveries

Name of Cities

Union Councils with Nutrition Services Delivery

Total No. of Union Councils

Faisalabad 63 56% 113

Rawalpindi 28 47% 60

Lahore 166 100% 166

Multan 34 68% 50

Gujranwala 19 30% 64

Total 310 68% 453

34

4.6.2 Type of Nutrition Services in Union Council s Data regarding the type of nutrition services were also obtained from 68 percent of union council (310 out of 453) where nutrition services were being delivered. It was reported that, three types of nutrition services were being delivered at various levels i.e. fixed services, school nutrition sessions and LHWs sessions on nutrition in the communities. It was reported that among 68 percent of union councils where nutrition services were being delivered, overall 45 percent were fixed sessions whereas 49 percent were the sessions being delivered by the LHWs. Only 6 percent were being delivered through schools. Lahore was the only city where all three types were delivered i.e. 7 percent fixed, 13 percent school nutrition sessions and 87 percent LHWs sessions on nutrition in the communities. [Table 40] shows the details of type of nutrition services being offered in 68 percent of union councils.

Table 40: Type of Nutrition Services Delivered in all Union Councils

Name of Cities Fixed Services School Nutrition Sessions

LHWs sessions on nutrition

Total

Faisalabad 63 56% 0 0% 0 0% 63

Rawalpindi 28 47% 0 0% 28 47% 56

Lahore 12 7% 22 13% 144 87% 178

Multan 34 68% 0 0% 0 0% 34

Gujranwala 19 30% 0 0% 0 16% 19

Total 156 45% 22 6% 172 49% 350

35

Chapter 5 EPI Facilities

5. Assessment of EPI Centers

36

Chapter 5: EPI Facilities This part describes the situation analysis of all 228 fixed EPI centers located in five largest cities of Punjab.

Key Highlights Overall in 228 fixed EPI centers located in five largest cities:

87 percent physical infrastructures of EPI centers were owned by the government 53 percent did not have SOP for child immunization 65 percent did not have gender segregated waiting areas 36 percent did not have adequate seating capacity for the female caregivers 38 percent did not have facility of drinking water for the patients and their attendants 31 percent did not have toilet facilities for the patients and their attendants 2 percent had less than six hours of working in a day 96 percent burnt and buried the waste accumulated at the centers 59 percent had Lady Health Visitors in their centers In Rawalpindi: 11 percent had non-functional IRL In Gujranwala: 83 percent faced shortage of vaccine during last one year

All these 228 EPI centers were physically visited by the study team. Box 3 shows the details of EPI centers located within the slums and underserved areas in five cities of Punjab i.e. Faisalabad, Rawalpindi, Lahore, Multan and Gujranwala.

The major indicators were: to assess the availability of equipment and supplies (including vaccines), availability of human resources, waste management, and timing as well as the availability of facilities for patients and their attendants at the EPI centers.

Data regarding the ownership of EPI centers’ infrastructure and availability of SOPs for child immunization were also gathered for the purpose of this study.

It is important to note that EPI centers were located into three different physical categories within the study areas.

Needless to mention, all these EPI centers within three categories were being run and managed by the government (Box 4).

5.1 Infrastructures 5.1.1 Ownership of EPI Centers’ Infrastructure Overall, majority of the physical infrastructures of EPI centers i.e. 87 percent (199 out of 228) were owned by the government whereas, remaining 13 percent (29 out of 228) were located into rented buildings. However, these 13 percent were also run and managed by the government. The city-wise data [Figure 20] shows that all EPI centers located into Faisalabad and Rawalpindi were completely owned by the government whereas in Lahore (94 percent), Multan (57 percent) and

Box 3: Number Of Epi Centers In Slums And Underserved Areas

Cities Total No. of EPI centers

Faisalabad 34

Rawalpindi 19

Lahore 127

Multan 30

Gujranwala 18

Total 228

SOURCE: Official Data by Department of Health

Box 4: Three Physical Categories Of Epi Centers Within The Study Areas

1. Some EPI centers were located into independent buildings. 2. Some EPI centers were accommodated with public healthcare facilities (i.e. primary, secondary and/or tertiary). 3. Some EPI centers were adjusted within private and welfare healthcare facilities.

100% 100%94%

57%50%

87%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 20: Percentage of EPI Centers Owned by the

Government

37

Gujranwala (50 percent) of EPI centers were owned by the government. Rest were located into rented buildings.

5.2 System 5.2.1 Availability of SOPs for Child Immunizations The respondents at EPI centers, located within the slums and underserved areas in five cities, were asked about the availability of standard operating procedures for child immunization in their respective EPI centers. It was reported that majority of the EPI centers i.e. 53 percent (120 out of 228) did not have this document for their staffs at the time of assessment by the study team.

The highest percentage of EPI centers without SOPs were reported from Gujranwala i.e. 89 percent whereas lowest percentage were from Faisalabad (21 percent). [Figure 21] shows the complete picture of EPI centers without SOPs.

Standard Operating Procedures (SOP) guide center staffs about the quality standards and help them avoid mal-practices. Availability of SOPs is a basic step towards its compliance. In the absence of basic document, its compliance and maintaining the quality standards becomes a challenge.

5.3 Management and Facilities 5.3.1 Waiting Areas 5.3.1.1 Availability of Waiting Areas The waiting areas were assessed from gender perspective and analysed for the availability of adequate and gender-segregated space for women. The cultural and religious requirements demand for a gender segregated waiting areas especially for the female caregivers.

It was reported that overall 65 percent (149 out of 228) of EPI centers did not have gender segregated waiting areas. The highest percentage of EPI centers without gender segregated waiting areas reported from Gujranwala (i.e. 78 percent), followed by Lahore (73 percent) and Faisalabad (65 percent). However, in Multan almost 60 percent EPI centers had gender segregated waiting areas, followed by Rawalpindi (58 percent). [Table 41] shows the details of EPI centers who had gender mixed and gender segregated waiting areas. It is interesting to correlate percentage of zero dose children in each city with the availability of gender segregated waiting areas.

Table 41: Percentage of gender mixed and segregated waiting areas in EPI centers

Study Sites Gender Mixed Gender Segregated Total

Faisalabad 22 65% 12 35% 34

Rawalpindi 8 42% 11 58% 19

Lahore 93 73% 34 27% 127

Multan 12 40% 18 60% 30

Gujranwala 14 78% 4 22% 18

Total 149 65% 79 35% 228

5.3.1.2 Availability of Seating Capacity for Females in Waiting Area It was reported that almost 36 percent (83 out of 228) of EPI centers located within slums and underserved areas did not have adequate seating capacity for the female caregivers. Table 42 shows the details of EPI centers who had adequate or inadequate seating capacity in the waiting areas for the female caregivers.

It is important to observe if the gender friendly spaces are provided, it will attract more women caregivers.

21%

63%51%

67%

89%

53%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 21: Percentage of EPI Centers without SOPs

38

Table 42: Percentage of seating capacity in waiting areas for female caregivers in EPI centers

Study Sites Adequate Capacity Inadequate Capacity Total

Faisalabad 21 62% 13 38% 34

Rawalpindi 13 68% 6 32% 19

Lahore 80 63% 47 37% 127

Multan 21 70% 9 30% 30

Gujranwala 10 56% 8 44% 18

Total 145 64% 83 36% 228

5.3.2 Drinking Water 5.3.2.1 Availability of Drinking Water It is extremely important to ensure availability of drinking water in the EPI facilities for caregivers.

Overall, 38 percent (86 out of 228) of EPI centers did not have facility of drinking water for the patients and their attendants. The highest percentage of EPI centers without drinking water facilities belonged to Gujranwala i.e. 72 percent and lowest from Faisalabad i.e. 12 percent. [Figure 22] shows the percentage of EPI centers without drinking water facility for the patients and their attendants.

5.3.3 Toilet Facilities 5.3.3.1 Availability of Toilet Facilities Data regarding the availability of toilet facilities were collected from all the EPI centers located in slums and underserved areas.

It showed that almost 31 percent (70 out of 228) of EPI centers did not have toilet facilities for the patients and their attendants. The highest percentage of EPI centers without toilet facilities were reported from Rawalpindi i.e. 42 percent (8 out 19). Similar pattern was observed in other three cities i.e. Gujranwala where 39 percent (7 out of 18), Lahore where 35 percent (45 out of 127), and Multan where 33 percent (10 out of 30) EPI centers did not have this facility. Faisalabad was the only city where all EPI centers (34 out of 34) had toilet facilities for the patients and their attendants. Figure 23 shows the percentage of EPI centers with toilet facilities. The unavailability of toilets is one of the major discouraging factors for women to visit these EPI centers especially from distant places.

5.3.3.2 Availability of Gender Segregated Toilet Facilities In 69 percent of EPI centers where toilet facilities were available (158 out of 228), it was reported that almost 44 percent (70 out of 158) did not have gender segregated toilet facilities.

12% 16%

42% 43%

72%

38%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

100%

58% 65% 67% 61%69%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

32%

82%

61%75%

27%

56%68%

11%

25%17%

44%

44%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Segregated Mixed

Figure 22: Percentage of EPI Centers without Drinking

Water Facility

Figure 23: Percentage of EPI Centers with Toilet

Facilities

Figure 24: Percentage of EPI Centers with Gender

Segregated and Mixed Toilet Facilities

39

This percentage was higher in EPI centers belonged to Faisalabad (68 percent), followed by Gujranwala (44 percent) and Lahore (25 percent). [Figure 24] shows the percentage of EPI centers with gender-segregated toilet facilities located within slums and underserved areas.

It is interesting to put a gender lens on them. The majority of women in Pakistan feel comfortable in using women specific toilet facilities. Some of the EPI centers had segregated use of toilets for specific genders while others had not segregated its use due to limited number of toilets available in the buildings.

5.3.3.3 Condition of Toilet Facilities In 69 percent of EPI centers where toilet facilities were available (158 out of 228), data regarding the condition of toilet facilities were also collected i.e. either toilets were cleaned and useable or not. It was reported that out of 69 percent of EPI centers where toilet facilities were available, almost 13 percent (21 out of 158) were not even in useable conditions that includes unavailability of water, filthiness or breakdown. Rawalpindi was the only city where all available toilet facilities were cleaned and useable in all EPI centers. [Figure 25] shows the percentage of EPI centers with unusable toilet facilities.

5.3.4 Working Hours The respondents were asked about the total working hours in their respective EPI centers located within slums and underserved areas.

It was reported that the normal working hours of EPI centers were eight hours. Out of these eight hours, two were dedicated for the record keeping tasks performed by the vaccinators whereas remaining six hours dedicated for the provision of vaccination services.

However, very small number of EPI centers in three cities i.e. Lahore (2 percent), Rawalpindi (5 percent) and Gujranwala (6 percent) reported that they had less than six hours of working. [Figure 26] shows the percentage of EPI centers with less than six hours of working.

It is important to ensure service provision according to laid down SOP.

5.4 Equipment and Supplies 5.4.1 Availability of Ice Lined Refrigerators The study team checked the availability and functionality of Ice Lined Refrigerators in all EPI centers located within the slums and underserved areas. It was observed that the EPI centers in all four cities i.e. Faisalabad, Gujranwala, Lahore and Multan had functional Ice Lined Refrigerators (ILR) in their respective centers. However, only 11 percent (2 out of 19) of the EPI centers in Rawalpindi had non-functional IRL. The major reasons behind unworkability of these ILR were technically damaged and power breakdown.

Table 43: Percentage Of EPI Centers With and Without Functional Ice Lined Refrigerators

Study Sites Available and Functional Available but Not Functional Total

Faisalabad 34 100% 0 0% 34

Rawalpindi 17 89% 2 11% 19

Lahore 127 100% 0 0% 127

Multan 30 100% 0 0% 30

Gujranwala 18 100% 0 0% 18

Total 226 99% 2 1% 228 It is important to ensure proper cold chain in all available EPI centers in order to continue uninterrupted quality provision of vaccine service delivery.

6%

0%

8%

20%17%

13%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

0%

5%

2%

0%

6%

2%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 25: Percentage of EPI Centers with Unusable

Toilet Facilities

Figure 26: Percentage of EPI Centers with less than 6

working hours

40

5.4.2 Availability of Essential Supplies The availability of some essential supplies i.e. auto disposable syringes, safety boxes (sharp containers), vaccines carriers and ice packs were also checked by the study team in all EPI centers located within slums and underserved areas.

Although, the EPI SOPs suggested that all centers must have full stock of vaccines and its related supplies for uninterrupted vaccination services, it was observed that only one city’s all EPI centers had 100 percent stock of all mentioned supplies i.e. Faisalabad. Interestingly, safety boxes / sharp containers were the only supply that was available in all EPI centers located with the slums and underserved areas. [Figure 27] shows the percentage of essential supplies available at EPI centers.

5.4.3 Supply of Vaccines When asked specifically, ‘did your EPI center experience any problem in getting vaccines during last one year?’ almost 93 percent EPI centers mentioned they did not face any problem. All the EPI centers from Rawalpindi, Multan and Lahore, reported that they did not face any problem in getting vaccines during last one year.

However, majority of the EPI centers in Gujranwala i.e. 83 percent (15 out of 18) reported that they had faced shortage but infrequent during last one year followed by Faisalabad i.e. 3 percent (1 out of 33).

In order to ensure uninterrupted vaccination service provision, it is important to ensure the sufficient stock of vaccine all the time.

Table 44: Percentage Of EPI Centers Faced Problem In Getting Vaccines During Last One Year

Study Sites Infrequent Shortage No Shortage Total

Faisalabad 1 3% 33 97% 34

Rawalpindi 0 0% 19 100% 19

Lahore 0 0% 127 100% 127

Multan 0 0% 30 100% 30

Gujranwala 15 83% 3 17% 18

Total 16 7% 212 93% 228

5.5 Waste Management 5.5.1 Process of Disposing Waste It was reported that majority of the EPI centers i.e. 96 percent (219 out of 228) burnt and buried the waste accumulated at the centers located within the slums and underserved areas of all five cities. However, only four percent (9 out of 228) reported the collection of waste by the waste management company (WMC) vehicle from their respective centers. [Figure 28] shows the percentage of EPI centers who used different types of waste management methods.

100% 100% 98%80%

100% 96%

0 0 2%20%

0 4%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Burn + Burry Collected by WMC vehicle

Figure 28: Percentage of EPI Centers with Types of

Waste Management

100% 79% 100% 100% 94% 98%

100%100%

100% 100% 100% 100%

100%89%

98% 100% 100% 98%

100%89%

98% 90% 100% 97%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Auto Disable Syrings Safety Boxes / Sharp Containers

Vaccine Carrier(s) Ice packs

Figure 27: Percentage of EPI Centers with Essential

Supplies

41

Waste management of supplies according to the laid down SOP is necessary to avoid its misuse particularly syringes. However, it is encouraging to see proper waste management practices in fixed EPI centers.

5.6 Human Resources 5.6.1 Availability of LHVs Although the primary purpose of the provision of LHVs in any of the healthcare facilities is to offer maternal and child health care (MCH) services, but they are also made responsible for the vaccination. The data showed that only 59 percent (134 out of 228) of EPI centers located in slums and underserved areas of all five cities had LHVs. The highest percentage of EPI centers with LHVs were reported from Faisalabad i.e. 76 percent (26 out of 34) whereas lowest percentage was from Gujranwala i.e. 22 percent (4 out of 18). [Figure 29] shows the percentage of EPI centers who had LHVs.

5.6.2 Availability of Vaccinators Similarly, the number of vaccinators for each EPI center varies but at least one vaccinator was available in all EPI centers located within the slums and underserved areas of all five cities. It is important to note that the number of vaccinators for each center varies according to their administrative status and population within the union council where they located. EPI centers located in the primary, secondary and/or tertiary public healthcare facilities have more than one vaccinator so that the large number of children can be catered on a daily basis. (Table 141 Annex 7)

76% 74%

57% 60%

22%

59%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 29: Percentage of EPI Centers who has LHVs

42

Chapter 6 Childhood Vaccination

43

Chapter 6: Childhood Vaccination

This part presents the analysis of vaccination coverage rates of children aged between 12 and 23 months. The coverage rates are correlated with the background characteristics of households and profile of mothers. This part comprehensively covers the four variables i.e. vaccination coverage, characteristics of mothers, characteristics of households, and characteristics of fully immunized children vs zero-dose children. Key Highlights Sample Size

3,863 children (aged between 12 and 23 months) of 3,856 mothers were part of this survey 3,852 households were visited that consists 26,886 family members 99 percent of the mothers had one child aged between 12 and 23 months

Retention of Vaccination Cards

61 percent children had vaccination cards 55 percent boys and 45 percent girls had vaccination cards

Fully Immunized Children

63 percent children were fully immunized (Records + Recall Basis) 50 percent children were fully immunized (Record Basis)

Antigen Wise Coverage (Record + Recall Basis)

Coverage rates BCG + OPV0 dose: 83 percent Coverage rates for Penta 1: 81 percent Coverage rates for Penta 2: 77 percent Coverage rates for Penta 3: 73 percent Coverage rates for Measles-1: 65 percent Coverage rates for Measles-2: 47 percent

Antigen Wise Coverage (Record Basis)

Coverage rates BCG + OPV0 dose: 60 percent Coverage rates for Penta 1: 60 percent Coverage rates for Penta 2: 58 percent Coverage rates for Penta 3: 56 percent Coverage rates for Measles-1: 51 percent Coverage rates for Measles-2: 36 percent

Partially Vaccinated

20 percent children were partially vaccinated (Record + Recall Basis) 11 percent children were partially vaccinated (Record Basis)

Zero Dose

17 percent children did not receive any antigen (on zero dose) Information about Working of LHWs

40 percent mothers did not have any information about LHWs working in area 71 percent preferred receiving vaccination awareness messages through TV

Characteristics of The Mothers

87 percent of mothers were aged between 20 and 35 years 35 percent of all mothers had no formal education 4 percent mothers were engaged in the livelihood

Characteristics of the Households

66 percent people spoken Punjabi 15 percent children lived in Kacha/tented housing structures 22 percent children lived in Kacha/Pacca housing structures 63 percent children lived in Pacca household structures 70 percent households did not have water supplied by the government

44

6 percent houses were lacking toilet facilities 49 percent families relied on daily wage labor for their income 51 percent mothers reported debt burden

Characteristics Of Fully Immunized Vs. Zero Dose Children

57 percent mothers of the children with zero dose had no formal education 27 percent mothers of fully immunized children had no formal education 35 percent families of zero dose children were residing in Kacha/tented houses 9 percent families of fully immunized children were residing in Kacha/tented houses 21 percent houses belonging to zero-dose children did not have any toilet facility 2 percent houses belonging to fully immunized children did not have any toilet facility 53 percent (houses belonging to the zero-dose children relied on daily wage work

49 percent houses belonging to the fully immunized children

6.1 Vaccination Coverage 6.1.1 Sample Size A total of 3,863 children (aged between 12 and 23 months) of 3,856 mothers living in 3,852 households were the part of this survey. Table 45 shows the units that were analyzed in the childhood vaccination coverage survey. These households had a total of 26,886 family members, with equal ratio of male and female (50 percent each). The largest sample of respondents were from Faisalabad (i.e. 6192 out of 26886) whereas, the smallest belonged of Multan (3625 out of 26886). Overall, the average family size was seven persons per household. The comparison of family size across five cities reflects, highest family size (nine) in Faisalabad and second highest (seven) in Rawalpindi. Lahore, Multan and Gujranwala had an average family size of six members per household.

Table 45: Units of Analysis in the Childhood Vaccination Coverage Survey

Study Sites Households Mothers Children

Faisalabad 708 712 716

Rawalpindi 824 824 826

Lahore 820 820 820

Multan 582 582 583

Gujranwala 918 918 918

Total 3852 3856 3863

More than 99 percent of the mothers (3849 out of 3856) had one child aged between 12 and 23 months while only seven mothers (7 out of 3856) had two children aged between 12 and 23 months at the time of the study.

6.1.2 Retention of Vaccination Cards It was reported that only 61 percent (2340 out of 3863) of children had vaccination cards. The highest vaccination card retention was found in Multan and Gujranwala (65 percent each), while lowest in Faisalabad (52 percent). Among those who had vaccination card (2340 out of 3863), the gender lens on the card retention were also analyzed. It was reported that out of 2340 children, 55 percent were boys whereas 45 percent were girls. (Table 156 Annex 8)

52%

62% 59%65% 65%

61%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 30: Retention of Vaccination Cards

45

The gender difference was higher in Multan i.e. 60 percent (boys vs 40 percent girls), followed by Faisalabad (58 percent, boys vs 42 percent girls). The unavailability of vaccination cards were highly linked with the lack of awareness regarding the importance of vaccination cards. [Figure 30] shows the percentage of children who had vaccination cards (2340 out of 3863).

6.1.3 Fully Immunized Children In this category, only those children were included who had received all antigens up to Measles-1. 6.1.3.1 Records + Recall Basis Overall, 63 percent (2448 out of 3863) of the children were fully immunized. The highest percentage of fully immunized children were found in Multan i.e. 76 percent (446 out of 583), followed by Rawalpindi i.e. 69 percent (567 out of 826) whereas, the lowest percentage was reported in Lahore i.e. 53 percent (437 out of 820), followed by Faisalabad i.e. 57 percent (405 out of 716). [Figure 31] shows the percentage of children who were fully immunized (Records + Recall Basis). 6.1.3.2 Records Basis Almost 50 percent of the children were fully immunized. However, percentage of fully immunized children dropped from 76 percent to 55 percent in Multan when checked against the records. Similarly, the percentage of fully immunized children dropped from 69 percent to 52 percent when checked against the records in Rawalpindi. [Figure 32] shows the percentage of children who were fully immunized (Records Basis). Overall, the percentage of fully immunized boys (55 percent) were higher than girls (45 percent). The significant gender variation was found in Multan where 60 percent boys were fully immunized compared to only 40 percent girls. Faisalabad was the only city where percentage of fully immunized boys (43 percent) were lower than the girls (57 percent). In Gujranwala i.e. 53 percent boys vs 47 percent girls, Lahore i.e. 54 percent boys vs 46 percent girls and Rawalpindi i.e. 52 percent boys and 48 percent girls were fully immunized. (Table 158 Annex 8)

6.1.4 Antigen Wise Coverage 6.1.4.1 Records + Recall Basis Although 83 percent of the children received BCG + OPV0 dose [Figure 33], the coverage rates for Penta 3 was only 73 percent [Figure 36] whereas, for Measles-1, it was 65 percent [Figure 37]. The coverage rates were relatively better in Multan where 92 percent children had received BCG + OPV0 and 79 percent of the children had received Measles-1. The coverage rates for BCG + OPV0 were lowest for Gujranwala (76 percent) while coverage rates for Penta 3 were lowest for Lahore (62 percent). The coverage for Measles-1 was lowest for Lahore (56 percent) and Faisalabad (58 percent).

57%69%

53%

76%65% 63%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

36%

52%47%

55% 57%

50%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 31: Fully Immunized Children (Record + Recall)

Figure 32: Fully Immunized Children (Records)

46

The comparison of dropouts for BCG + OPV0 to Penta 3 and BCG + OPV0 to Measles-1 reflected higher percentage of dropouts for Measles-1. Overall, the dropout rates from BCG+OPV0 to Penta 3 were 12 percent while the dropout rates from BCG+OPV0 to Measles-1 were 22 percent [Figure 38]. Faisalabad (36 percent) and Lahore (29 percent) had the highest dropout from BCG+OPV0 to Measles-1. The lowest percentage of dropouts from BCG+OPV0 to Measles-1 were found in the slums/underserved areas of Rawalpindi (12 percent), Gujranwala (14 percent) and Multan (14 percent). The high percentage of dropout could be due to multiple reasons i.e. weak follow ups and rapid movement of caregivers from one place to another. The correlations between percentages of dropout and zero dose reflected that

90%81% 79%

92%

76%83%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

88%81%

73%

91%

75%81%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

82% 80%

67%

89%

70%77%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

75% 77%

62%

84%

69%73%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

58%71%

56%

79%65% 65%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

17%

5%

22%

9% 9%12%

36%

12%

29%

14% 14%

22%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Defaulters % BCG to Penta 3 Defaulters % BCG to Measles 1

Figure 35: Coverage Rates for Penta 2 (Records +

Recall)

Figure 33: Coverage Rates for BCG OPV 0

(Records + Recall)

Figure 34: Coverage Rates for Penta 1

(Records + Recall)

Figure 36: Coverage Rates for Penta 3

(Records + Recall)

Figure 37: Coverage Rates for Measles I (Records

+ Recall)

Figure 38: Percentage of Defaulter for Penta 3 &

Measles 1

47

Although Faisalabad had highest dropout rates from BCG+OPV0 to Measles-1 (36 percent) compared to other four cities but the percentage of zero dose was lowest (9 percent) there. This highlights that Faisalabad requires child registry and strict follow up. The facts for Lahore were different where percentages from BCG+OPV0 to Measles-1 dropout (29 percent) and zero dose (20 percent) were equally high without much difference. 6.1.4.2 Record Basis Overall coverage rates for BCG+OPV0 and Penta 1 were 60 percent whereas, they were 58 percent and 56 percent for Penta 2 and Penta 3 respectively. The coverage rates for Measles-1 were even lower at 51 percent and Measles-2 at 36 percent [Figure 39]. The comparison of city wise coverage revealed that the coverage rate for BCG + OPV0, Penta 1, Penta 2 and Penta 3 were highest for Gujranwala and Multan whereas, they were lowest for Faisalabad for all these antigens. The highest coverage rates for Measles-1 were from Gujranwala (58 percent) whereas, the lowest coverage rates were from Faisalabad (36 percent).

6.1.5 Partially Vaccinated 6.1.5.1 Records + Recall Basis Overall, 20 percent (768 out of 3863) children were partially vaccinated on records and recall basis [Figure 40]. The highest percentage of partially vaccinated children were in Faisalabad (34 percent), followed by Lahore (27 percent) whereas, the lowest percentage of partially vaccinated children were in Gujranwala (11 percent), followed by Rawalpindi (13 percent). It is important to co-relate partially vaccinated children for each city with the percentage of zero dose children. Faisalabad had the highest percentage of partially vaccinated children but lowest percentage of zero dose children (9 percent). 6.1.5.2 Records Basis Overall, 11 percent children were partially vaccinated based on the records [Figure 41]. The highest percentage of partially vaccinated were found in Faisalabad (16 percent) while the lowest percentage of partially vaccinated children were found in Gujranwala (8 percent). Lahore (12 percent), Rawalpindi and Multan (10 percent each) had almost same range of partially vaccinated children. The percentage of partially vaccinated children on recall and records dropped from 20 percent to 11 percent when checked against the records only. City wise

52% 61% 58% 65% 65% 60%

51% 61% 57% 64% 65% 60%51%

60% 55%63% 63% 58%

50%58% 53%

58% 62%56%36%

53%49%

56% 58%51%28%

34% 44%43% 34%

36%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

BCG Penta 1 Penta 2 Penta 3 Measles 1 Measles 2

34%

13%

27%

16%

11%

20%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

16%

10%12%

10%8%

11%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 39: Antigen Wise Coverage (Records Basis)

Figure 40: Partially Vaccinated (Records + Recall)

Figure 41: Partially Vaccinated (Records Basis)

48

Comparison reflected that the lowest drop of percentage was in Multan where percentage of partially vaccinated (based on the records and recall basis) dropped from 16 percent to 10 percent only when checked against the records. In the case of Faisalabad, the percentage of partially vaccinated children dropped from 34 percent to 16 percent when checked against the records. 6.1.6 Zero Dose Almost 17 percent children (647 out of 3863) did not receive any antigen (on zero dose) [Figure 42]. The city wise variations indicated that the highest share of zero dose children were in Gujranwala (24 percent) whereas, the lowest share were in Multan (8 percent), followed by Faisalabad (9 percent). The gender lens on the vaccination status reflected that 56 percent (364 out of 647) zero dose children were boys compared to 44 percent (283 out of 647) girls. The trend was same across all the cities and more noticeable in Faisalabad where majority (63 percent) of the zero dose children were boys in contrast to girls (37 percent). (Table 164 Annex 8)

6.1.7 Reasons of Zero Dose A total of 647 children’s mothers who were not vaccinated (zero dose) were asked about the reason behind zero dose. It was reported that almost 28 percent reported ‘fear of injection’ as one of the major reasons behind zero dose, followed by ‘vaccination causes more diseases’ i.e. 25 percent and ‘unavailability of time (wastage of time) for vaccination’ i.e. 23 percent. Almost 11 percent reported that they did not get permission from family members for vaccination. [Table 46] shows the detail reasons behind zero dose to children [Figure 43].

Table 46: Reasons Of Zero Dose Children

Reason(s) Percentage (%)

Fear of injection 28

Vaccination causes more diseases 25

Unavailability of time for vaccination / wastage of time 23

No Permission from family members 11

Unaware of vaccination timings 6

Unaware of EPI/ outreach centre 4

Unaware of childhood vaccination 4

No enabling environment in EPI centers 1

6.1.8 Information about Working of LHWs Almost 40 percent of the mothers did not have any information about the working of LHWs in their areas [Figure 44]. Of those who were aware, either believed that they provided health education or supply family planning products. Gujranwala had the maximum percentage of mothers (89 percent) who were unaware about the working of LHWs whereas, this percentage was low for Multan (5 percent).

9%

18%20%

8%

24%

17%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

15%17%

13%

9%

5%

11%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

39%

25% 28%

5%

89%

40%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Figure 42: Children with Zero Dose

Figure 43: No Permission for Vaccination

Figure 44: Information about Working of LHWs

49

6.1.9 Preferred Channels of Communication Mothers (a total of 3856) were asked about the preferred channels of communication for receiving information (messages) on vaccination. It was reported that the highest percentage of mothers i.e. 71 percent (2725 out of 3856) preferred receiving messages through television whereas 38 percent preferred front line health workers, followed by poster (billboards) i.e. 24 percent [Figure 45]. However, leaflet was the least popular source of information on vaccination.

6.2 Characteristics of the Mothers In order to comprehend the actual reasons of low or no coverage, it was important to know the background characteristics of the mothers. Three major variables i.e. mother’s age, education levels and engagement in livelihood activities were surveyed by the study team.

6.2.1 Age The majority (87 percent) of mothers’ age were between 20 and 35 years. Over 11 percent mothers were 35+ years while only 2 percent were under 18 years of age. The ratio was same across all cities. (Table 170 Annex 8)

6.2.2 Educational Levels Almost 35 percent (1354 out of 3856) of all mothers had no formal education, whereas 19 percent had completed their primary education (1 to 5 years), while 33 percent mothers had 6 to 10 years of education. The highest proportion of mothers with no formal education were in Lahore (51 percent) whereas lowest were in Gujranwala (17 percent). The education status of mothers was relatively better in Gujranwala where 43 percent mothers had 6 to 10 years of education and 16 percent had completed their 11+ years of education. (Table 171 Annex 8)

6.2.3 Engagement in Livelihood Only a small percentage of mothers i.e. 4 percent (164 out of 3856) were engaged in the livelihood activities while 96 percent mothers (3692 out of 3856) were serving as homemakers. Almost 9 percent mothers in Multan were employed which were the highest share across five cities whereas lowest percentage of mothers (2 percent) who were employed reported from Faisalabad. (Table 172 Annex 8)

6.3 Characteristics of the Households The background characteristics of households were checked to know the family background, living conditions and economic pressures. Five major variables were analyzed i.e. language spoken to know the ethnic background, housing structures, access to domestic water, availability of toilet facility in household, primary occupation, and status of debt/savings on a monthly basis.

6.3.1 Commonly Spoken Languages Punjabi was the most commonly spoken language (66 percent) whereas Urdu was the second most commonly spoken language (18 percent). A combination, including Siraki and Pashto, was spoken in 14 percent households. Punjabi was the most commonly spoken language of Faisalabad (97 percent) whereas, Siraiki was the commonly spoken language in Multan (48 percent).(Table 173 Annex 8)

6.3.2 Housing Structures Almost 15 percent children lived in Kacha/tented and 22 percent in Kacha/Pacca combination houses whereas 63 percent lived in Pacca household structures [Figure 46].

16%

24%

31%

38%

71%

22%

Leaflet

Radio

Poster/Billboard

Health Worker

T.V

Others

Figure 45: Preferred Channels of Communication

for Vaccination Messages

50

The highest percentage of Kacha/tented houses were in Lahore (21 percent) whereas, the lowest percentage of Kacha/tented houses were in Faisalabad (10 percent). The majority of houses (63 percent) had 2 to 3 rooms whereas, 24 percent of houses had only one room. Multan had the highest percentage (71 percent) of houses with 2 to 3 rooms. Almost 5 percent of the houses were without operational electricity connections. (Table 175 Annex 8)

6.3.3 Access to Domestic Water Almost 70 percent of the households did not have water supplied by the government. Those who had this facility, majority of the houses (67 percent) had water available only for 1 to 5 hours. Gujranwala had the lowest percentage of houses (2 percent) with government-supplied water. The majority of households used ground water i.e. 59 percent. Around 11 percent houses purchased water for domestic use i.e. Gujranwala (21 percent), Rawalpindi (14 percent) and Faisalabad (12 percent). (Table 177 Annex 8)

6.3.4 Household Toilet Facilities Almost six percent (227 out of 3852) houses were lacking toilet facilities and practiced either open defecation or used neighbor’s toilet facility. The situation was worst in Lahore with 10 percent houses without toilet facilities, followed by Rawalpindi (9 percent). For houses where toilets were available, 42 percent (1616 out of 3852) houses had traditional and open pit toilets. The trend, however, varied across cities and was more noticeable in Faisalabad where majority of the houses (70 percent) were having traditional and open pit toilets in comparison to Multan (26 percent). (Table 179 Annex 8) In 50 percent houses, on average, 5 persons were using single toilet facility on a daily basis whereas almost 38 percent houses were those where 10 persons used one toilet on average in a day. Faisalabad had the maximum number of houses (12 percent) where around 15 or more members were using one toilet facility on average in a day. (Table 180 Annex 8)

6.3.5 Primary Occupations Almost 49 percent (1880 out of 3852) families relied on daily wage labor for their income whereas, 23 percent (873 out of 3852) families earned income from small businesses. Faisalabad had the maximum number of households where daily wage was the major source of income (62 percent) whereas, Multan had the highest number of households that were engaged in small businesses (30 percent). (Table 182 Annex 8)

6.3.6 Debt Burden Overall, 51 percent mothers reported debt burden while the highest percentage of mother reporting debt burden were found in Faisalabad (56 percent), and lowest in Multan (44 percent). (Table 183 Annex 8)

10% 16%21%

15% 12% 15%

37%

21% 16%11%

22% 22%

54%62% 62%

74%66% 63%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Kacha Kacha-Pacca Pacca

Figure 46: Housing Structures in Slums and Underserved Areas

51

6.4 Characteristics Of Fully Immunized Vs. Zero Dose Children 6.4.1 Mothers with No Formal Education Almost 57 percent (368 out of 647) mothers of the children with zero dose had no formal education in comparison to 27 percent mothers of fully immunized children [Figure 47]. The majority of mothers of children with zero dose were reported from Lahore (92 percent), followed by Rawalpindi (79 percent) who had no formal education. The lowest percentage of mothers with no formal education who had children with zero dose were found in Gujranwala (18 percent). One of the mothers in slums of Lahore stated that, “I still remember the day when I was married to my husband. I was only 14 years old and in the 8th grade. I had ambitions of pursuing higher education and making something out of myself so that I could have a better life than my parents had and could choose a better life for my children-to-be. It seems it was not in the destiny, after all”.

6.4.2 Living in Kacha Housing Structures Almost 35 percent families of zero dose children were residing in Kacha/tented houses, in contrast to 9 percent of fully immunized children. Variations were observed in all five cities. In Lahore, 60 percent families of the zero dose children were living in Kacha/tented houses whereas this number was only 4 percent for Multan. Similarly, almost 18 percent families of zero dose children were residing in Kacha/Pacca houses and 47 percent in Pacca houses.

6.4.3 Availability of Toilet Facility in the Household Almost 21 percent (135 out of 647) houses belonging to zero-dose children did not have any toilet facility whereas, 2 percent (44 out of 2441) houses of fully immunized children did not have toilet facility [Table 47 and Figure 49]. The variations were most noticeable in Lahore (where 36 percent) and Rawalpindi where (34 percent) families of zero dose children did not have toilet facilities. In comparison to this, none of the families of fully immunized children in Lahore were without toilet facility and only 2 percent of fully immunized children’s families in Rawalpindi were without toilet facility.

30% 34% 27% 30%15%

27%

61%79%

92%

36%18%

57%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Fully Immunized Children Children with Zero Dose

8% 9%4%

16%10% 9%

31%40%

60%

4%

19%

35%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Fully Immunized Children Children with Zero Dose

5% 2% 0% 1% 1% 2%

27%34% 36%

2% 3%

21%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Fully Immunized Children Children with Zero Dose

Figure 47: Fully Immunized Children Vs. Children with Zero

Dose of Mothers with No Formal Education

Figure 48: Fully Immunized Children Vs. Children with Zero

Dose living in Kacha Housing Structures

Figure 49: Fully Immunized Children Vs. Children with Zero

Dose in Houses without Toilet Facilities

52

Table 47: Fully Immunized Children Vs. Children With Zero Dose in Houses Without Toilet Facilities

Study Sites Fully Immunized Children Total Zero Dose Children Total

Faisalabad 20 5% 400 18 27% 67

Rawalpindi 11 2% 566 50 34% 149

Lahore 0 0% 437 60 36% 167

Multan 5 1% 445 1 2% 47

Gujranwala 8 1% 593 6 3% 217

Total 44 2% 2441 135 21% 647

6.4.4 Caregivers Working on Daily Wages The comparison among the families of zero dose and fully immunized children indicated that majority of the houses belonging to the zero-dose children i.e. 66 percent (424 out of 647) relied on daily wage work, whereas this share was 43 percent (1050 out of 2441) in the case of families belonging to fully immunized children [Figure 50]. The pattern was same across the cities. In Lahore, 77 percent families of zero dose children relied on daily wage work in contrast to lesser share for families of fully immunized children (37 percent). Likewise, financial debt was more common in caregivers of zero-dose children when compared to fully immunized children.

6.4.5 Debt Burden Financial debt burden on caregivers were higher in zero dose children i.e. 53 percent (346 out of 647) compared to caregivers of fully immunized children i.e. 49 percent (1199 out of 2441) [Figure 51]. Although the comparative percentages were not significant on total but these were very significant for caregivers of zero dose children in Faisalabad. Another important observation across city was: financial debt burden on caregivers generally was low in Rawalpindi and Multan. The reasons of low debt burden could be linked with the sources of income as these two cities had relatively lower percentage of caregivers engaged in daily wage work.

59%42% 34% 34% 42% 43%

85%

68% 77%53% 52%

66%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Fully Immunized Children Children with Zero Dose

55% 42% 54% 43% 53% 49%

78%

57%53%

47%46% 53%

Faisalabad Rawalpindi Lahore Multan Gujranwala Total

Fully Immunized Children Children with Zero Dose

Figure 50: Fully Immunized Children vs. Children with Zero

Dose of Families Working on Daily Wages

Figure 51: Fully Immunized Children Vs. Children with Zero

Dose of Families Who Had Debt Burden

53

Chapter 7 Conclusion

54

Chapter 7: Conclusion

7.1 Conclusion The highest number of slums/underserved areas were found in Lahore while the lowest number in Rawalpindi. Overall, 9.3 million people were residing in slums/underserved areas, which was almost half of the total population of five cities. The comparison of demographics reflects that the highest population resides in slums/ underserved areas of Lahore while the lowest population resides in Multan. Although the majority of residents were living in slums for more than two years, a quarter of them were temporary displaced particularly in Rawalpindi and Faisalabad. A small percentage of population residing in slums of Rawalpindi and Multan belonged to other nationalities. Analysis of health and EPI resources at the UC level reflected that more than a quarter of the UCs were without any health and or EPI facilities. A similar pattern was observed for LHWs and nutrition services. Almost 22 percent UCs were uncovered by the LHWs and 28 percent of UCs were uncovered for nutrition services. Access of residents of slums/underserved areas to health and EPI facilities was beyond two kilometers as less than 1 percent slums/underserved areas reported their access to public healthcare facilities within two kilometers while only 7 percent slums/underserved areas reported their access to EPI centers within two kilometers. More than a quarter of the total slums/underserved reported non-presence of outreach vaccination as well. The above factors highlighted the status of access of residents of slums/underserved areas to healthcare services and these could be directly correlated with a higher percentage of zero dose and partially vaccinated children across five cities especially in Gujranwala. The coverage assessment reflected that 17 percent children had not received any antigens hence were zero dose while 20 percent children had received some doses partially hence were partially vaccinated. The highest percentage of zero dose were found in Gujranwala (24 percent) which could be because only 1 percent slums/underserved areas in Gujranwala had mentioned easy access to fixed EPI centers. Although Lahore also had the second highest percentage of zero dose children (20 percent) but this could be directly linked with the distance of EPI center and effectiveness of outreach vaccination services as only 4 percent slums and 10 percent underserved areas reported easy access to the EPI center. While 83 percent slums and 67 percent underserved areas confirmed having been recipients of outreach vaccination services. If the percentage of zero dose in slums/underserved areas were 20 percent in Lahore, this could either be because of ineffective outreach or low demand for childhood vaccination services. The gender lens on EPI centers reflected the non-presence of gender segregated waiting areas or inadequate seating capacity in waiting areas. Similarly, gender segregated toilet facilities or unusable toilets were also found in some EPI centers. Unavailability of drinking water especially during hot summers was also found in some EPI centers. These three aspects could be some of the discouraging factors for female caregivers to access EPI centers conveniently. Gender lens on coverage assessment data sets reflected that female family members were exactly half of the other gender while registered girl child were less than equal half (45 percent). This could be because some of the families consider a female child to be a sign of honor and hence keep her hidden from public appearance. Therefore, independent coverage assessment data had a lower number of registered female children as compared to male children.

7.2 Study Limitations

1. The profiling of slums / underserved areas is done by conducting interactive group interviews. There is a possibility of exaggeration and biased input from the participants due to prevailing group dynamics.

2. The study provides accurate listing of the slums and provides substantial details on the profiling of the slums. However, since it is a sample based study, the input from the sample does not precisely represents the true opinion of the entire slum population.

3. Although the study provides an insight into the water and sanitation conditions of the dwellers of slums/underserved areas, the study does not, in detail covers the hygiene of water in terms of water safety for human consumption. The study also does not cover the poor sanitation related ordeals of the slum dwellers.

4. The data on existing healthcare facilities has been collected from the department of health. It has been organised and analysed under the existing study but the healthcare facilities (except

55

EPI centers) located in the union councils, were not physically visited and verified by the study team.

5. The data presented on EPI centers is the observation/input of the survey team and information provided by the technical staffs / doctors. The department of health may have a different information about EPI centers in their records.

6. The profiling of slums/underserved areas was conducted to have a cursory view of the situation therefore participatory groups discussions were conducted in each slum and underserved areas. Since the detailed house to house information has not been collected from the residents, some of the information may have exaggeration according to the participants of the group.

7. The status of vaccinations explored through childhood vaccination coverage survey in the community were not triangulated with the data obtained from fixed EPI centers through assessment. Therefore, the survey records for recall basis may have some variation.

8. The childhood vaccination coverage survey was conducted only with mothers of children aged between 12 and 23 months, living in slums/underserved areas. The majority of mothers were either had no formal education or had very low levels of education. Their responses may have some understanding gaps.

9. Since majority of the respondents of coverage survey were mothers with no formal education therefore the status of vaccination on recall basis has limited reliability.

10. Since majority of the mothers of zero dose children had no formal education therefore reasons of zero dose may have missed some more aspects.

11. Almost 75 percent population (slums and underserved areas) has access to school (i.e. access to primary education) in the study areas. However, type and quality of school education had not been assessed.

56

Chapter 8 Recommendations

Muskaan - The Child of Poverty

Muskaan lives in Syed Town Katchi Abadi in Rawalpindi. She is a mother of

1 year child who is born in poverty and is being raised in poverty. Her house

consists of 4 mud rooms and has a total of 25 members living in them. The

residents of this household are of Pashtoon descent and therefore, the

commonly spoken language of the household is Pashto. Though the

electricity connection is available for their home, there is no government

supply of water and daily water for consumption is to be bought. Muskan’s

mother reported difficulty in managing the cleanliness related chores of the

household. There is only one traditional toilet available for the 25 members

of the house. Muskan’s father is a daily wage laborer and his family has been

residing in Syed Town since the last 20 years.

Muskaan’s mother is a 40 years old woman without formal education who

spends her entire day taking care of the family. Muskan’s mother, while

talking about vaccination states that, “on the suggestion of a Lady Health

Worker, Muskaan was vaccinated after six weeks of her birth but after that

she has not been vaccinated for any other disease”.

Muskaan’s mother contends that they have several other livelihood related

issues and therefore, they pay minimal attention on the ‘luxury’ of

preventive healthcare.

57

Chapter 8: Recommendations In this study, following recommendations are made according to the gaps in health resources and coverage rates in slums / underserved areas.

8.1 Service Delivery 1. Improve the availability and accessibility of health and EPI centers for the residents of slums /

underserved areas. It is important to utilize the private sector healthcare facilities for improving the access of slums / underserved areas of vaccination services.

2. Total timings and duration for offering vaccination services shall be reconsidered, as per the preference of caregivers. In this regard, either flexible hours for the outreach vaccination services) or double shifts can be introduced for the vaccination services in fixed EPI center, as per the convenience and availability of residents of slums / underserved areas.

3. Upgradation of Standard Operating Procedures shall be ensured as per the current changes in the system and practices. Staffs shall be trained followed up for its adherence.

4. Gender specific infrastructure facilities shall be provided into EPI centers. For example, women and men specific waiting areas with adequate seating capacity, women and men specific functional clean toilets and drinking water facilities may enhance the visits of women caregivers.

5. Availability of vaccines and its supplies shall be ensured without any interruption.

8.2 Demand Generation and Communication 6. Design targeted demand generation strategy, which not only target the caregivers of the

children but also offer tools for raising awareness among family members. The community awareness sessions to increase the knowledge of residents can be helpful in eliminating the misconceptions and to maximize their understanding of the overall safety and efficacy of vaccines in the slums and underserved areas.

7. Design literacy programmes for improving the maternal education level. Literacy could be utilised as a medium for raising awareness on the importance of immunization.

8. Use channels of communication preferred by the mothers and other community members so that importance of childhood immunization could be understood and practices accordingly.

9. Facilitate LHWs in raising awareness among caregivers on the importance of childhood immunization.

10. Regular follow ups of caregivers by front line health workers (vaccinators or LHWs or social organisers or local community activists) before and after the outreach vaccination in their respective areas.

8.3 Health Work Force 11. Vaccinators shall be facilitated in preparing realistic micro plans and covering children living in

both planned and unplanned areas (slums). 12. A proper system shall be designed for tracking newborns and moving population to prepare

realistic micro plans. 13. Performance-based payment system shall be introduced together with an effective

performance management measures. For example, offer non-financial incentives to high performing LHWs and vaccinators such as certificate for the best employee. Any LHW or vaccinator securing 12 certificates consecutively could be recommended for salary increments etc. This would improve the coordination and team work between LHWs and vaccinators.

14. Offer periodic performance based incentives to the vaccinators shall be given to improve the effectiveness of outreach vaccination services.

8.4 Gender in Immunization 15. Ensure LHVs deployment in all EPI centers to attract women caregivers. 16. Ensure administration of vaccinations in private healthcare facilities, which offer maternal,

neonatal and child health (MNCH) services.

8.5 Practical vs. Strategic Needs 17. Coordinate and combine vaccination services together with public and private welfare initiatives

that contribute to the improvements in economic conditions of urban poor. This would directly contribute the increase in coverage rates and address their strategic problems.

58

18. Almost 19 percent slums are unregistered or illegal. The lack of official recognition make these communities prone to evictions and deprived of basic healthcare facilities. The provision to secure tenure for slum dwellers is prerequisite in order to receive the basic services delivery.

19. The existing study is good for conducting further thematic research which in turn can inform detailed thematic planning.

8.6 Others 20. Almost 97 percent (98 percent from slums and 96 percent from underserved areas) were not

aware from the emergency services of 1038 offered by the government to respond emergency related situation of pregnant women. It would be important to explore the reasons behind unawareness of this service so that adequate strategies can be devised for improving its utilization.

59

Annex 1: Questionnaire for Group Interviews in Slums & Underserved Areas

PART A

BS02 Name of facilitator of group interview

BS04

What is the name of your province? Select from below by typing the correct number: 1. Punjab 2. KP 3. Balochistan

BS05 Enter the name of your city

BS06 Enter name of your town

Bs07a What is the NEW NAME of this Union Council?

BS07b What is the NEW NUMBER of this Union Council?

BS08a What is the OLD name of this UC? If there is no OLD name, type X

BS08b What is the OLD NUMBER of this UC? If there is no old number, type X

BS09 Is this a ... 1. Slum 2. Underserved area

GP1 If you accidentally selected a wrong option in this section and would like to go back to correct it, please press G. If you have entered all correct information and would like to proceed, press P

BS10 Please turn on the GPS or "Location Services" on your mobile phone/handset. You will now be required to share your location while you are in the slum. Press the "Share location" button.

PART B

SP01 Please share current publicly known name of slum or underserved area (this should be name of the slum/underserved area that is also used in their postal address)

SP02

What is the status of registration of slum or underserved area with the relevant government department? Type 1 if its registered, or 2 if its unregistered

1. Registered 2. Unregistered

SP03 Do you have documentary evidence? Type 1 for "yes" or 2 for "no". Skip if answer to question S02 is no.

1. Yes 2. No

SP04 Which year was this area established?

SP05a What is the name of the nearest landmark of this area?

SP05b Please enter distance in kilometers from the slum/underserved area to the landmark

SP06 How many mohallas do you have in this slum or underserved area?

SP07a How many total families live in this slum or underserved area?

SP07b What is the total population of this slum/underserved area?

SP08a Are you aware of immunisation? If the answer to this question is no then skip questions SP08b to SP08h 1. Yes 2. No

SP08b

Have you ever heard about immunisation through any communication source? Skip if answer to questions SP08a is no (For the following questions, try not to prompt respondents; rather let them answer themselves and you can type Yes or No to make the selection) 1. Yes 2. No

SP08c Did you receive information about immunisation through TV? Skip if answer to questions SP08a is no 1. Yes 2. No

SP08d Did you receive information about immunisation through Radio? Skip if answer to questions SP08a is no 1. Yes 2. No

SP08e

Did you receive information about immunisation through a poster/bill board? Skip if answer to questions SP08a is no 1. Yes 2. No

SP08f Did you receive information about immunisation through a leaflet? Skip if answer to questions SP08a is no 1. Yes 2. No

SP08g

Did you receive information about immunisation through health workers? Skip if answer to questions SP08a is no 1. Yes 2. No

SP08h Did you receive information about immunisation through neighbors? Skip if answer to questions SP08a is no 1. Yes 2. No

GP2 Ok. If you accidentally selected a wrong option in this section and would like to go back to correct it, please press G. If you have entered all correct information and would like to proceed, press P

60

PART C

MT01

Do you have families other than permanent residents living here? If answer to this question is no then skip questions MT02b 1. Yes 2. No

MT02a What is the number of permanent resident families settled here? Please enter number of FAMILIES only, and not individuals

MT02b What is the number of temporary displaced families settled here? Please enter number of FAMILIES only, and not individuals. If none, type 0. Skip this question if answer to the question MT01 is no

MT02c What is the number of nomad families settled here? Please enter number of FAMILIES only, and not individuals. If none, type 0. Skip if answer to questions SP08a is no

MT02d What is the number of families from conflict affected areas that are settled here? Please enter number of FAMILIES only, and not individuals. If none, type 0. Skip if answer to questions SP08a is no

MT02e What is the number of non-Pakistani families settled here? Please enter number of FAMILIES only, and not individuals. If none, type 0. Skip if answer to questions SP08a is no

MT02f Any there families settled other than explained in answers to the earlier questions? Please enter number of FAMILIES only, and not individuals. If none, type 0. Skip if answer to questions SP08a is no

MT03

Do families such as nomads come and settle here in certain months and move back in certain months? Skip if answer to questions SP08a is no 1. Yes 2. No

MT04a In which month do they generally come? Please share name of the month. Skip if answer to questions SP08a is no

MT04b In which month do they generally leave the slum or underserved area? Please share name of the month. Skip if answer to questions SP08a is no

MT05 Who are the top 3 most influential persons to whom people listen and follow in this slum or under served area? Please mention their names as well as their designations or identity, e.g., 1). Hafeez Shan, Numberdar 2) Murad Khan, Counsellor, 3) Waheed Aslam, Molvi/Imam

GP3

Have you entered all the names and designations? If not, press Q to go back to this question and enter names and destinations in ONE line. If you accidentally selected a wrong option in this section and would like to go back to correct it, please press G. If you have entered all correct information and would like to proceed, press P

PART D

HF01

Are there any functional public or private health facilities having MBBS qualified doctors in this slum or underserved area? If answer to this question is no then skip questions from HF02a to HF02d 1. Yes 2. No

HF02a If there are any functional health facilities having MBBS qualified doctor then how many of these are public health facilities? Reply with a number. If there are none, type X. Skip this question if the answer to the question HF01 is no

HF04

Please share distance of nearest Public health facility located within your slum or underserved area in kilometers from the centre of your slum or underserved area. Skip this question if the answer to the question HF01 is no. Type a number from the select: 1) 0 - 1 Km 2) 1 - 2 Km 3) 2 - 3 Km 4) 3 - 4 Km 5) 4 - 5 Km 6) 5 + Km

HF05a

Does this public health facility offer the service of vaccination of children? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF05b

Does this public health facility offer the service of maternal and child health care? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF05c

Does this public health facility offer the service of administration of polio drops? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF05d

Does this public health facility offer the service of obstructive care and delivery? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF05e Does this public health facility offer any other facilities? Skip this question if the answer to the question HF01 is no If yes, please describe. If none other, type X

HF 06 Does this public health facility have functional ambulance?

61

1. Yes 2. No

HF02b How many Private profit making health facilities having MBBS doctor are located in this slum or underserved area? Reply with a number. If there are no private health facility in this slum or underserved area then type X

HF07.

Please share distance of nearest private facility (for-profit) in kilometers from the centre of the area. Type a number from the select: Skip this question if the answer to the question HF01 is no 1) 0 - <1 Km 2) 1 - <2 Km 3) 2 - <3 Km 4) 3 - <4 Km 5) 4 - <5 Km 6) 5 + Km

HF 08.

Does this private for-profit health facility have functional ambulance? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF09a.

Does this private for-profit facility offer vaccination of children? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF09b.

Does this private for-profit facility offer maternal and child health care services? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF09c.

Does this private for-profit facility offer the service of administration of polio drops? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF09d.

Does this private for-profit facility offer obstructive care and delivery services? Skip this question if the answer to the question HF01 is no 1. Yes 2. No

HF09e. Does this private for-profit facility offer any other services? If yes, please describe what those services are in meaningful text and correct spellings. If the private health facility does not offer any other services defined in earlier questions then type "X". Skip this question if the answer to the question HF01 is no

HF02c. How many health facilities having MBBS qualified doctor located in your slum or underserved area are run by any WELFARE or TRUST? Reply with a number. If none of the health facilities are run by any welfare or trust then type X. Skip this question if the answer to the question HF01 is no

HF02d.

Are there any other types of functional health facilities having MBBS qualified doctor which are not been mentioned by you in the answers of earlier questions? If yes how many of these are located in your slum or underserved area. Please answer in number. if there is no health facility other than already explained in the answers of earlier questions then type X. Skip this question if the answer to the question HF01 is no

HF10.

Do your slum or underserved area utilize transport services offered by the government for any health related emergencies? 1. Yes 2. No

HF11a.

Does your slum or underserved area utilize services of 1122 by the government to respond to any domestic accidental emergency? 1. Yes 2. No

HF11b.

Do your slum or underserved area utilize services offered by 1038 by the government to respond to emergency related to the situation of pregnant women? 1. Yes 2. No

HF11c. Are there any other emergency services available for the residents of this slum or underserved area? If yes, please describe it. If no other type of services are offered other than already answered in earlier questions then type "X"

HF12.

Do Lady Health Workers work in this slum or underserved area? if the answer to this question is no then skip questions fromHF13a to HF14f 1. Yes 2. No

HF13a. How many LHWs work here? Enter number only. Skip this question if answer to question HF12 is no

HF13b. Please enter full names of LHWs who work here. Skip this question if answer to question HF12 is no

HF14a.

Do these LHWs provide awareness to mothers on pregnancy related matters? Skip this question if answer to question HF12 is no 1. Yes 2. No

HF14b.

Do these LHWs provide awareness to mothers on child health problems? Skip this question if answer to question HF12 is no 1. Yes 2. No

HF14c. Do these LHWs raise awareness on importance of family planning? Skip this question if answer to question HF12 is no

62

1. Yes 2. No

HF14d.

Do these LHWs distribute medicine for child care? Skip this question if answer to question HF12 is no 1. Yes 2. No

HF14e.

Do these LHWs raise awareness on immunisation and polio campaigns? Skip this question if answer to question HF12 is no 1. Yes 2. No

HF14f. Do LHWs provide any other services which are not described in the answers of earlier questions then explain these in a meaningful sentence. If no other services which are already not explained are provided by LHW then type X. Skip this question if answer to question HF12 is no

HF15. Are there any health workers who are working on dengue? 1. Yes 2. No

GP4 If you accidentally selected a wrong option in this section and would like to go back to correct it, please press G. If you have entered all correct information and would like to proceed, press P

PART E

EP01.

Are there any vaccination services offered for children and women in this slum or underserved area? if the answer to this question is no then skip questions from EP02a to EP02f 1. Yes 2. No

EP02a

Are there any fixed EPI facilities for vaccination in this slum or underserved area? Skip this question if answer to question EP01 is no 1. Yes 2. No

EP03.

Who is running this fixed EPI facility? Skip this question if answer to question EP01 is no 1. Government 2. Private 3. Welfare organisation 4. Cantonment 5. Other

EP04.

What is the average distance of the facility from the centre of the slum? Skip this question if answer to question EP01 is no 1. 0 - 1 Km 2. 1 - 2 Km 3. 2 - 3 Km 4. 3 - 4 Km 5. 4 - 5 Km 6. 5 + Km

EP02b.

Are there adhoc outreach vaccination camps in this slum or underserved area? Skip this question if answer to question EP01 is no 1. Yes 2. No

EP02c.

Do Lady Health Workers do the vaccination? Skip this question if answer to question EP01 is no 1. Yes 2. No

EP02d.

Are there adhoc overnight stay of mobile vaccinators for vaccination camps Skip this question if answer to question EP01 is no 1. Yes 2. No

EP02e.

Do doctors in private health facility do the vaccination? Skip this question if answer to question EP01 is no 1. Yes 2. No

EP02f. Are there any system for vaccination in this slum or underserved area which is not explained in the answers to earlier questions? If yes, please explain in a meaningful sentence and there is no other system for vaccination which is not explained in earlier questions then type X. Skip this question if answer to question EP01 is no

GP5 If you accidentally selected a wrong option in this section and would like to go back to correct it, please press G. If you have entered all correct information and would like to proceed, press P

PART F & G

WA01.

What is the MAIN source of drinking water only for majority of the houses of this slum or underserved area? 1. Government water supply 2. Well 3. Hand pump 4. Buy from water tankers 5. Buy from the water man (mashkee) 6. Tube wells 7. Other

63

WA02.

What is the MAIN source of water for domestic purposes for the majority of the houses of this slum or underserved area? 1. Government water supply 2. Well 3. Hand pump 4. Buy from water tankers 5. Buy from the water man (mashkee) 6. Tube wells 7. Other

WA03. If running water through any water supply system is available in this slum what is the duration of water availability? Please enter number of hours, e.g., type "4" if the water comes for 4 hours. If no running water available, type X

TO01.

Are toilets available in any of the houses of this slum or underserved area? Skip questions TO02a if the answer to this question is no 1. Yes 2. No

To02a. Approximately how many houses of this slum or underserved area have toilets? Enter number only. If the answer to the question TO01 is no then skip this question

To02b. How many total houses of this slum or underserved area do NOT have toilets? Enter number only. if answer of TO02a is less than the total number of houses in this slum or underserved area then this question will filled otherwise skip it

To02c. How many total houses are located in this slum or underserved area? Enter number only. (This question is asked to check that the answer to the question TO02a and To02b should not be greater than the total houses located in this slum or underserved area

TO 03a

If toilet exists in any of the houses of this slum or underserved area, please specify how many flush to sewage toilets are there? (Flush to sewage toilet refers to sewer connected pour flush toilet fixed with a household and main sewer outside the house leading to a disposal point or sedimentation tank) Please enter NUMBER of such type of toilets only. If there are none, type 0. Skip if answer to question TO01 is no

TO 03b

If toilets exists in any of the houses of this slum or underserved area, please specify how many traditional latrine pits/vaults are there in the slum/underserved area? (constructed over simple dug well without any p-trap provision) Please enter NUMBER of such type of toilets only. If there are none, type 0. Skip if answer to question TO01 is no

TO 03c

If toilets exists in any of the houses of this slum or underserved area, please specify how many open pits are there in the slum/underserved area which people use as toilets? Please enter NUMBER of such type of toilets only. If there are none, type 0. Skip if answer to question TO01 is no

TO 03d Please specify if there are ANY OTHER types of toilets in the slum/underserved area which we have not asked you about yet. If so, please describe what type and how many are there. If there is no other type, type X. Skip if answer to question TO01 is no

TO 04. If toilet exists in all or some of the houses of this slum or underserved area, please explain approximately how many persons in majority of the houses share one toilet? Enter number only. Skip if answer to question TO01 is no

To05.

If there are houses without any toilets in this slum or underserved area then where do generally men and women go for defecation? 1.Neighbor’s toilet 2.Public toilet 3.Open defecation 4. Other

GP6 If you accidentally selected a wrong option in this section and would like to go back to correct it, please press G. If you have entered all correct information and would like to proceed, press P

PART H, I & J

TH 01a. How many total houses are located in this slum or underserved area

TH 01b. How many houses of this slum or underserved area have kacha type of infrastructure as the main residential area of the household? If yes, please enter answer in number only. If there are no kacha houses in this slum or underserved area then type X

TH 01c. How many houses of this slum or underserved area have pakka type of infrastructure as the main residential area of the household? If yes then enter answer in number only. If there are no pakka houses in this slum or underserved area then type X

TH 01d. How many houses of this slum or underserved area have mixed type of infrastructure (partially pakka and partially kacha) as the main residential area of the household. If yes then enter answer in number only. If there are no houses having mixed infrastructure in this slum or underserved area then type X

TH 01e.

How many houses of this slum or underserved area have tented type of infrastructure as the main residential area of the household? If yes then enter answer in number only. If there are no tented houses in this slum or underserved area then type X

TH01f

Are there houses in this slum or underserved area having infrastructure other than explained in earlier questions as the main residential area of the household? If yes then enter answer in number. If there are no houses constructed in infrastructure other than explained above in this slum or underserved area then type X

SWM 01a

Are there any paved or unpaved drains in this slum or underserved area.If the answer to this question is no then skip question SWM01b

1. Yes 2. No

64

SWM 01b

What is the condition of drains regarding disposal of waste water? 1. Drains have running water 2. Drains are filthy 3. Drains are choked 4. Any other

SWM02a.

Is there any system available for disposal of solid waste in this slum or underserved area? If the answer to this question is no then question SWM02b will be skipped 1. Yes 2. No

SWM 02b.

What is the system for the disposal of solid waste in this slum or underserved area? Type a number to select from the following list. Skip this question if answer to the question SWM02a is no 1. Government/WMC vehicle comes to pick 2. Welfare organisation arrange disposal with some intervals 3. Residents dump it on an empty plot 4. Residents throw it on streets 5. Any other

ED 01.

Are there schools in this slum or underserved area? If the answer to this question is no then skip questions ED02a to ED03e 1. Yes 2. No

ED02a.

Are there schools by government? Skip this question if the answer to question ED01 is no 1. Yes 2. No

ED02b.

Are there for profit schools by private sector? Skip this question if the answer to question ED01 is no 1. Yes 2. No

ED02c.

Are there schools by welfare trust or charity? Skip this question if the answer to question ED01 is no 1. Yes 2. No

ED02d.

Are there any maktab schools by religious group(s)? Skip this question if the answer to question ED01 is no 1. Yes 2. No

ED02e.

Are there any other type of schools which are not explained while answering earlier questions? If yes, please describe what type of schools in meaning full text and correct spellings. If there are no schools types which are not explained in earlier questions then type X. Skip this question if the answer to question ED01 is no

Ed03a.

What is the approximate distance of nearest school (it could be any type of school) from the centre of the slum or underserved area? Type a number to select: Skip this question if the answer to question ED01 is no 1. Less than 1 km 2. Between 1-2 km 3. Between 2-3 km 4. Between 3-4 km 5. More than 4 km

GP7 If you accidentally selected a wrong option in this section and would like to go back to correct it, please press G. If you have entered all correct information and would like to proceed, press P

PART K

CSO 01.

Are there any not for profit registered welfare or charity organisation working in this slum or underserved area (NGOs-CSOs)? If the answer to this question is no then skip questions from CSO02a to CSO05 1. Yes 2. No

CSO 02a. If registered not for profit organisations are working in this slum or underserved area, please mention its number? This question will be answered if the answer to question CSO01 is yes otherwise type X. Skip this question if answer to the question CSO1 is no

CSO3a. If registered not for profit organisations are working in this slum or underserved area, please share their full names in correct spellings. Skip this question if the answer to question CSO01 is no otherwise type X

CSO 04

Are there any informal groups or committee working in this slum or underserved area? If answer to this question is no then skip question CSO07 1. Yes 2. No

65

CSO05

Do the informal groups/committees include the following. Skip this question if the answer to the question CSO06 is no 1. Health committee 2. School committee 3. Masjid committee 3. Jirga or punchait 4. Zakat committee 5. Unregistered Community Based Organisation 6. All of the above 7. Some of the above 8. If other than stated above then explain in meaningful text in correct spellings

CSO 06a

Are there any public welfare schemes or initiatives by government? If answer to this question is no then skip questions CSO08b, CSO08c, CSO08d, CSO08e, CSO08f 1. Yes 2. No

CSO06b

Does the government provide a loan scheme? Skip this question if the answer to the question CSO08a is no 1. Yes 2. No

CSO06c Does the government provide a stipend scheme? 1. Yes 2. No

CSO06d

Does the government provide a Social Benefit Card scheme? Skip this question if the answer to the question CSO08a is no 1. Yes 2. No

CSO06e

Does the government provide a vocational skills scheme? Skip this question if the answer to the question CSO08a is no 1. Yes 2. No

CSO06f

Are there any other types of government scheme for the welfare of people of slum or underserved area which is not explained in the answers of earlier questions? If the answer is yes, please explain it in a meaningful text and correct spelling and if there is no other type of welfare scheme by the government then type X. Skip this question if answer to the questionCSO08a is no

CSO7a

Are there any public welfare schemes or initiatives by private sector or welfare trust etc.? If the answer to this question is no then skip question CSO09b to CSO09c 1. Yes 2. No

CSO07b

Does this non-government source provide a loan scheme? Skip this question if answer to the question CSO09a is no 1. Yes 2. No

CSO07c

Does this non-government source provide a stipend scheme? Skip this question if the answer to the question CSO09a is no 1. Yes 2. No

CSO07d

Does this non-government source provide a Social Benefit Card scheme? Skip this question if the answer to the question CSO09a is no 1. Yes 2. No

CSO07e

Does this non-government source provide a vocational skills scheme? Skip this question if the answer to the question CSO09a is no 1. Yes 2. No

CSO07f

If there are any other type of welfare schemes which are not explained in the answers to the earlier questions then explain it in meaningful text and correct spelling. If there is no other type of welfare scheme which is explained in the earlier questions then type X. Skip this question if the answer to question CSO09a is no

Now you will be required to enter names and phone numbers of participants of this focus group discussion (minimum three names and numbers required).

Participant 1 name ------------------------------ Participant 1 number----------------------

Participant 2 name-------------------------------- Number---------------------------------

Participant 3 name------------------------------- Number---------------------------------

66

Annex 2: Questionnaire for Household Coverage Survey

Name of Enumerator

Date of interview

Select your province by typing the number from below, e.g., 2 for KP: 1. Punjab 2. KP 3. Balochistan

Enter district name

Enter Union Council name

Enter the name of location

HHM1 Is this location a slum or underserved 1. Slum 2. Underserved

Enter name of household head

Enter household number. Please insert household numbers as 1, 2 , 3 etc. as you begin filling questionnaires from different households

Enter Converted ID number (CID) Marziya: Please move this to the end of the survey and ensure this appears on the dash board so that supervisors can insert converted ID number Instructions for Supervisors: The logic of having Converted ID number (CID) is to ensure a unique ID for each HOUSEHOLD. The household number cannot be unique as different enumerators will collect data from different households on the same time and will enter household number of their own such as 1, 2, 3 etc. Once data collection by all enumerators is completed for the day, the supervisor or Team Leader) enter CID for each of the completed interviews on the MS EXCEL sheet. The supervisor should know the last CID entered. This will be continued in the following day. The supervisor will enter CIDs considering the last CID entered in the previous day.

If you have accidentally chosen the wrong answer in any of the questions in this section, please press "G" to go back to it and correct it. If you would like to proceed to the next section, press "P"

HHMa Thanks! You will now be asked few questions on household socio economic information. How many members are currently living in your household?

HHMb How many of them are males? Please write your answer in numbers e.g. 2, 3, 4

HHMc How many females are in the household? Please write your answer in numbers e.g. 2, 3, 4

SE01 Since how long you (and your family members) are living here in this house/slum? Enter the duration in number of years and months, e.g, 2 years and 3 months

SE02

If you have migrated from another place in the last 2 years, can you please pick a reason from the list below for coming/migrating to this slum? years If you have been here for more than 2 years, please type 6 1. To find a job/better life 2. Came from conflict affected area 3. We are displaced temporarily 4. We are nomads 5. Any other reason 6. Living here since for more than two

In case of nomads please specify the reason for moving and write this correct spellings and complete meaningful sentence

SE03

Which language is primarily used in your house with family members? Type the correct number from below: If they choose 8: Please write which language is primarily spoken at home and not stated in the above mentioned list of languages 1. Urdu 2. Punjabi 3. Potohari 4. Balochi 5. Pashto 6. Sindhi 7. Siraiki 8. Other

SE04

What is type of infrastructure of main living room/bedroom of the house? If they choose 5: Please specify what is the other type of infrastructure of the main room of the house in correct spellings and complete meaningful sentence 1. Kacha 2. Pakka 3. Mixed 4. Tented 5. Other type of infrastructure

SE05 How many (living rooms and bedrooms) are in the house? (Do not include kitchen, toilet, cattle-shed etc). Please write your answer in number only e.g. 1 or 2 or 3

SE06 How many members were in the house yesterday including any guests? Please write your answer in number only e.g. 1 or 2 or 3

SE07 Is electricity available/installed in your house? Please write your answer either in 1 or 2 or yes or no

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1. Yes 2. No

SE08

What is the main source of water for ALL PURPOSES in your house? If they select 7, please specify the water source in words other than stated above 1. Government water supply 2. Well 3. Hand pump 4. Buy from water tankers 5. Buy from the water man (Mashkee) 6. Tube wells 7. Other

SE09

What is the main source of DRINKING water? If the answer is other than specified the above please specify it in correct spelling and meaningful sentence 1. Government water supply 2. Well 3. Hand pump 4. Buy from water tankers 5. Buy from the water man (Mashkee) 6. Tube wells 7. Other

SE10

Do you have running water system installed in your house The answer could be in 1 or 2 or in yes or no if the answer is no then skip to question SE12 1. Yes 2. No

SE11 If the running water system is installed in your house, then what is the duration of water availability? Please write your answer in number of hours only, e.g., 4 if there is no running water, type X

SE12

Do you have functional or useable latrine available within your house? Please write your answer either in 1 or 2 or yes or no If the answer is no then skip to question number SE15 1. Yes 2. No

SE13

If you have toilet in your house, please specify its type of toilet/latrine, which is used by elder family members (not by children)? (Please check the availability of toilet if conveniently possible) Please write your answer in numbers by selecting from the stated list. If they select option 5, they will be taken to SE15 1. Flush to sewage 2. Traditional latrine pit/vault 3. Open pit 4. None/bush/field 5. Any other type of toilet

SE14 If you do have toilet in your house, how many people share one toilet in the house? Please write your answer in number only

SE15

If you do not have toilet in your house, where do you go for defection? If they choose 4: Please specify your answer in correct spellings and complete meaningful sentence 1. Neighbour's toilet 2. Public toilet 3. Open defecation 4. Other

SE16

What is the primary source of income of the household? Please write your answer in numbers by selecting from the stated list. If they choose 7: Please specify the primary source of income in correct spelling and complete meaningful sentence 1. Government Job 2. Private job (factory worker, etc.) 3. Work in foreign country 4. Small business (shop keeper, etc.) 5. Work as daily wage labors 6. Taxi driver 7. Other

SE17

Tell us the economic/income situation of your household (Reference period is last one year) Please write your answer in numbers by selecting from the stated list. 1. Always deficit 2. Occasional deficit 3. No deficit, no surplus (even) 4. Surplus in income

GP1 If you have accidentally chosen the wrong answer in any of the questions in this section, please press "G" to go back to it and correct it. If you would like to proceed to the next section, press "P"

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Household Survey Questionnaire Part B It is about knowledge, behaviors and practices of mothers on immunization. Repeat this questionnaire if there is more than 1 mother in this house

Enter Converted ID number (CID)

Please enter mother number, e.g., type "1" if its the first mother of the house you are interviewing

Please enter mother's mobile number if mother does not have a mobile number, please record mobile number of any other family member who lives in the same house

SD01 How old are you? Please write your answer in number of years e.g. 20, 25, 30 etc.

SD02 How many years of schooling did you finish? Please write your answer in numbers e.g. 0,1, 2, 3, 4 etc.

SD03

Are you employed outside home? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

SD04 How many children under the age of 2 do you have? Please write your answer in number e.g. 1, 2, 3, 4 etc.

KP01

Have you ever heard of childhood vaccination or immunization or EPI from any of the sources? Please write your answer either in 1 or 2 or yes or no. If the answer is no then please skip to question KP04a 1. Yes 2. No

KP02

Please tell us the purposes of vaccinating or immunizing children? If they select option 2, please specify the purpose of vaccination in a correct spelling and complete meaningful sentence 1. To protect from diseases 2. Other purpose 3. Do not know

KP03a

Have you ever received information about childhood vaccination or immunization through TV? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP03b Have you ever received information about childhood vaccination or immunization through radio? 1. Yes 2. No

KP03c

Have you ever received information about childhood vaccination or immunization through a poster or a bill board? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP03d

Have you ever received information about childhood vaccination or immunization through a leaflet? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP03e

Have you ever received information about childhood vaccination or immunization through health workers/LHVs? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP03f

Have you ever received information about childhood vaccination from sources other than specified above? Please write your answer either in 1 or 2 or yes or no. If yes, please specify it in a correct spelling and complete meaningful sentence. 1. Yes 2. No

KP04a Do you know if there is any fixed EPI facility in your slum or under served area? 1. Yes 2. No

KP04b

Have you gotten your children immunised? Please write your answer either in 1 or 2 or yes or no If the answer to this question is no then skip to question K06 1. Yes 2. No

KP05a Did you ever get immunisation services for your child or got your child immunised from a fixed public EPI facility? Please write your answer either in 1 or 2 or yes or no

1. Yes 2. No

KP05b

Did you ever get immunisation services for your child or got your child immunised from an outreach vaccination camp? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP05c

Did you ever get immunisation services for your child or got your child immunised through a Lady Health Worker? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

69

KP05d

Did you ever get immunisation services for your child or got your child immunised through a doctor in private health facility? Please write your answer either in 1 or 2 or yes or no 1. Yes 2. No

KP05e

Did you ever get immunisation services for your child or got your child immunised from EPI facility other than specified above? Please write your answer either in 1 or 2 or yes or no if the answer is yes, then specify the type of facility from where the child got immunisation services in a correct spelling and complete meaningful sentence. 1. Yes 2. No

KP06

If you do not get your child immunised, please share reason for not getting your child immunised? If the answer is other than the listed in points 1-10, please specify in correct spelling and complete meaningful sentence. 1. Was not aware of EPI/outreach center 2. Did not know the timing/hours 3. Did not have time to go 4. No enabling environment in EPI center 5. Transport cost/opportunity cost 6. Family/husband did not allow 7. Fear of injection 8. It is haram 9. It causes more diseases 10. Wastage of time 11. Other

KP07

Have you ever heard of Lady Health Workers (LHWs) working in your area? Please write your answer either in 1 or 2 or yes or no If they select option 2, they will be taken to GP2 1. Yes 2. No

KP08

Please tell us what they (LHWs) do? (As the interviewer, do not read the following options to the respondent. Pick the correct number from below based on the answer they give on their own) If they select option 9 or 10, they will be asked: "What all do LHWs do in this area? Please specify" 1. Visit household 2. Promote health education 3. Supply FP methods 4. Treat illnesses 5. Refer to hospital 6. Vaccinate/help vaccinator 7. Don't know 8. All of the above 9. Some of the above 10. None of the above

GP2 If you have accidentally chosen the wrong answer in any of the questions in this section, please press "G" to go back to it and correct it. If you would like to proceed to the next section, press "P"

Household Questionnaire Part C It is about immunization status of children under 2. For each child ask her mother to answer the following question

Enter Converted ID number

Please enter mother number, e.g., if you are interviewing the 2nd mother of the same house, type "2"

Please enter mother's mobile number if the mother does not have mobile number please get the number of any other family member who lives in the same house

For every child under the age of 2, ask his/her mother the following questions

CH01 What is the sex of child? 1. Male 2. Female

CH02 What is the age of child in months? If the age of the child is in days, please specify number with a word e.g. 01 year, 009 months or 15 days

CH03

Has the child ever been given vaccine? Please write your answer either in 1 or 2 or yes or no If the answer to this question is no then skip to question CH12 1. Yes 2. No

CH04

If the child was given any vaccine, please ask the mother to show the vaccination card? If the card is available then answer yes or 1 (If card is available, then use it to record immunization status of the child below. Ask the following question if the child has not received all expected doses). If card is not available then record the status of vaccination on re-call basis. 1. Yes 2. No

CH05 Has the child ever been given BCG vaccination immediately after the birth? You may ask first dose of the vaccine

70

Please write your answer either in 1 or 2 or yes or no Interviewer: Confirm if BCG is given by asking how was given, any scar mark on the arm of the child. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH06

Has the child been given OPV to protect him/her from getting polio immediately after the birth or later? This is usually given with BCG. Please write your answer either in 1 or 2 or yes or no Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH07

Has the child' been given Penta 1 at the age of 06 weeks or later? Please write your answer either in 1 or 2 or yes or no Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH08

Has the child' been given Penta 2 at the age of 10 weeks or later? Please write your answer either in 1 or 2 or yes or no Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH09

Has the child' been given Penta 3 at the age of 14 weeks or later? Please write your answer either in 1 or 2 or yes or no Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH10

Has the child' been given Measles 1 at the age of 09 months or later? Please write your answer either in 1 or 2 or yes or no Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH11

Has the child' been given Measles 2 at the age of 15 months or later? Interviewer: Confirm by asking more questions. The question can be filled by verifying it from the vaccination card or on recall basis 1. Yes 2. No

CH12

Ok. Does this mother have another child under 2 years of age? Please write your answer either in 1 or 2 or yes or no. If they select option 1, they will get the message: "Let’s start interviewing her" and Part B of the questionnaire will start running again. If they select option 2, they will receive the message: "Thanks. Your responses have been recorded and the interview has ended. 1. Yes 2. No

71

Annex 3: Questionnaire for District or Town Health Office

Basic Information

BS 01. Date: _ _ / _ _ / 201_

BS 02. Name of Assessor:

BS 03. Signature of Assessor:

BS 04. Name of Province:

BS 05. Name of District:

BS 06. Name of Town / Tehsil:

BS 07. New Name of Union Council:

BS 08. Record longitude and latitude of the Town Health Office 1. Longitude:………………..

2. Latitude:………………….

This questionnaire is designed to compile data of health and EPI

facilities and human resources at union council level.

BS09. Record the time of interview

Hours : Minutes

2. __ __ : __ __

Tehsil/Town Information

TI 01.How many Union Councils are in this Town/Tehsil? Number…………………………..

TI 02. Enlist new and old names and number of all the Union Councils of this Town/Tehsil.

# List of New Name of

Union Council

List of Old name of

Union Council

List of New Number

of Union Council

List of Old Number of

Union Council

TI 03. Enlist Union Council wise names of slum or underserved area if available. (you may attach separate list of slums or

underserved area in case of long list)

# New Names of Union Council Name of slums Name of underserved area

TI 04. What is the population in each Union Council? (Kindly mention population including and excluding population of slum

or underserved area). Please define source of population size as well

# New Names of

Union Council

Population of Slum

or underserved

area

Population of Union Council

(Excluding Population of Slum or

underserved are

Total Population of

Union Council

Public Healthcare Facilities And Human Resources

HF 01. How many Public and Private Health Facilities are in each Union Council?

# Names of Union Council List of Public Health

Facilities

HF 02. How many Public and Private Health Facilities are located in slum or underserved areas?

# New Names of

Union Council

Name of slum or

underserved area

List of Public

Health Facilities

List of Private

Health Facilities

Total

HF 03. How many Lady Health Worker are currently active in each Union Council?

# Names of Union Council List of Lady Health Workers

HF 04. Is Dengue staff working in union council 1. Yes

2. No

HF 05. If yes, then how many staff members are working Total

Nutrition

NU 01. Any nutrition service delivered in the Union Councils? 1. Yes

2. No

NU 02. If yes than what type of nutrition services are delivered? 1. Fixed

2. Temporary

3. School Nutrition Session

4. LHW Sessions on Nutrition in Communities

9. Other…………………

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Vaccination

VA 01. How many Fixed EPI Facilities (Vaccination centers) are available in each Union Council?

# Names of

Union

Councils

List Public of

Fixed EPI

Facilities

List of

Private Fixed

EPI Facilities

List of

Welfare

Fixed EPI

Facilities

List of Any

Other Type

of Fixed EPI

Facilities

No EPI

Facility

VA 02. State the number and functionality of ILR or Refrigerator in Fixed EPI Facility (vaccination centers)?

# Names of Union

Council

Public Fixed EPI

Facilities

Private

Fixed EPI

Facilities

Welfare Fixed

EPI Facilities

Any Other Type of Fixed

EPI Facilities

Functional Non

Funct

ional

Func

tiona

l

Non

Fun

ctio

nal

Funct

ional

Non

Functi

onal

Functional Non

Function

al

VA 03. What is the number and status of availability of currently active vaccinator?

# New Name of Union

Council

List of

vaccinator in

Public Health

Facility

List of vaccinator

in Private

Health Facility

List of Vaccinator in Fixed EPI

Facility (vaccination center)

established by other than public

sector organisation

73

Annex 4: Questionnaire for EPI Center Assessment

Objective: This questionnaire will be used for the assessment of fixed EPI center and undertake group interview with the facility team.

Category 1: Identification

Identification Answer and code

1.1. Date of assessment

1.2. Name of assessor

1.3. Signature of assessor

1.4. Name of Province

1.5. Name of District

1.6. Name of Town (or Tehsil)

1.7. Name of the EPI center

1.8. Record longitude and latitude of the fixed EPI center ……. Longitude ……. Latitude

1.9. Take photo of the fixed EPI center 1 – Photos taken 2 – Not taken

1.10. Code for fixed EPI center

Category 2: Infrastructures, System and Facilities at EPI centers

2.1 What is the type of building (rented, owned)? 1 - Rented 2 - Owned 9 - Other (specify):

2.2 Are Standard Operating Procedures for child immunizations available in this facility at the time of visit? 1 – Yes (Assessor: Please verify) 2 – Not available today 3 – Facility never had guidelines

2.3 Are disposable syringes with disposable needles available in this facility at the time of visit? 1.-Yes 2.-No

2.4 Are auto disable syringes available in this facility at the time of visit? 1.-Yes 2.-No

2.5 Are sharp containers available in this facility at the time of visit? 1.-Yes 2.-No

2.6 Are vaccine carrier(s) available in this facility at the time of visit? 1.-Yes 2.-No

2.7 Set of icepacks for vaccine carriers available in this facility at the time of visit? 1.-Yes 2.-No

2.8 Anything else available in this facility at the time of visit which we have not asked about? If yes please specify and if not available type X

2.9 Does this facility has refrigerator or fridge / SDDs available at the time of visit with power supply for the storage of vaccines? Please physically verify the answer. 1 – Available with power supply 2 – Available but no regular power supply 3 – Refrigerator is out of order 4 – No refrigerator is available

2.10 Did the facility experience any problem in getting vaccines in last one year? 1 – No 2 – Yes, sometimes 3 - Yes, facility has frequent shortage of supplies 4. – Other (specify):

Category 3: Management and Human Resources

3.1 What types of immunization services are available in this facility?

1 - Routine immunization for <2

2 - Protection from MNT (TT) for WCBAs

3 – Other (specify):

3.2 What antigens are offered for children and women? Please tick the offered antigens.

3.3 How many vaccinators are currently providing services in the slum or underserved areas in your district or

tehsils? If there are no vaccinators type X

…………Vaccinators

3.4 How many LHVs are currently providing services in the slum or underserved areas in your district or tehsils? If

there are no LHVs type X

…………….LHVs

3.5 Are vaccinators and LHVs available in this facility on a full time basis?

1 – Yes (Assessor: Please verify this information if respondent says yes)

74

2 - No

3.6 What are the timings of this fixed health facility open? type number only “8” (24 hours format)

Opens at: ………

3.7 What are the timings of this fixed health facility closed? type number only “15” (24 hours format)

Closes at: …………

3.8 What are total working hours of the facility per day? Type a number only e.g.“8”

Total working hours………..

Category 4: Facilities and Waste Management

4.1 Is there any waiting area (separate for men and women patients) in the facility?

1 – Yes, separate for men and women

2 – Yes, mixed waiting area for men and women

3 – No waiting area available

4.2 Is adequate seating capacity/ arrangement available in the waiting area?

1 - Yes, has adequate seating capacity

2 – No, seating capacity is not adequate

9 – No seating area available /NA

4.3 Is drinking water available for patients and their attendants in the facility?

1 – Yes

2 - No

4.4 Is toilet facility available for both men and women patients and their attendants in the facility?

1 – Yes, separate for men and women

2 – Yes but NOT separate for men and women

3 – No toilet facilities available

4.5 Is the toilet facility clean and usable for patients and their attendants in the facility?

1 – Yes, clean and usable

2 – Yes, clean but no water supply

3 – Not usable and safe

4.6 How health facility/ EPI waste is being disposed from the site

1. Berried

2. Burnt

3. Incineration

4. Dumped in health facility / garbage cane

5. Others

75

Annex 5: Analysis of Profiling of Slums/Underserved Areas

Table 48: Number of Slums and Underserved

Cities Slums Underserved Sub Total

Faisalabad 169 297 466

Gujranwala 82 165 247

Lahore 356 637 993

Multan 216 104 320

Rawalpindi 76 62 138

Punjab Total 899 1265 2164

Table 49: Timeframe Existence of Slums

Cities Before 1950 1950-1990 1991-2005 After 2005 Total

Faisalabad 17 110 35 7 169

Gujranwala 17 48 13 4 82

Lahore 76 224 42 14 356

Multan 32 129 45 10 216

Rawalpindi 15 46 11 4 76

Punjab Total 157 557 146 39 899

Table 50: Registration Status of Slums

Cities # of slums in each city

Registered slums Unregistered slums Sub Total

Faisalabad 169 151 18 169

Gujranwala 82 47 35 82

Lahore 356 293 63 356

Multan 216 180 36 216

Rawalpindi 76 58 18 76

Punjab Total 899 729 170 899

Table 51: Population

Cities Population in Slums Population in Underserved Areas Sub Total

Faisalabad 459,327 881,049 1,340,376

Gujranwala 289,610 1,179,940 1,469,550

Lahore 1,519,936 3,130,318 4,650,254

Multan 491,250 432,270 923,520

Rawalpindi 532,155 434,844 966,999

Punjab Total 3,292,278 6,058,421 9,350,699

Table 52: Types of Residents in Slums

Cities Permanent Resident Temporary Displaced Other Nationality Total

Faisalabad 68,766 16,639 0 85,405

Gujranwala 54,154 2,155 0 56,309

Lahore 213,394 31,918 105 245,417

Multan 91,111 12,752 707 104,570

Rawalpindi 69,149 18,295 3,102 90,546

Punjab Total 496,574 81,759 3,914 582,247

Table 53: Types of Residents in Underserved

Cities Permanent Resident Temporary Displaced Other Nationality Total

Faisalabad 131,586 27,639 12 159,237

Gujranwala 170,230 16,178 0 186,408

Lahore 411,531 47,064 1,527 460,122

Multan 63,005 6,064 350 69,419

Rawalpindi 60,066 13,749 300 74,115

Punjab Total 836,418 110,694 2,189 949,301

Table 54: Types of Residents in Slums and Underserved (Total)

Cities Permanent Resident Temporary Displaced Other Nationality Total

Faisalabad 200,352 44,278 12 244,642

Gujranwala 224,384 18,333 0 242,717

Lahore 624,925 78,982 1,632 705,539

Multan 154,116 18,816 1,057 173,989

Rawalpindi 129,215 32,044 3,402 164,661

Punjab Total 1,332,992 192,453 6,103 1,531,548

76

Table 55: Number of Health Facilities

Slums Underserved

Cities Public Private Welfare/Trust

Other Total Public Private Welfare/Trust

Other Total Grand Total

Faisalabad 0 2 0 0 2 0 0 0 0 0 2

Gujranwala 0 0 0 0 0 1 4 0 0 5 5

Lahore 3 0 0 0 3 0 0 0 0 0 3

Multan 4 0 0 0 4 0 0 0 0 0 4

Rawalpindi 2 0 0 0 2 0 0 0 0 0 2

Punjab Total

9 2 0 0 11 1 4 0 0 5 16

Table 56: Slums having Private and Public Health Facilities

Cities With Public Health Facilities

With Private Health Facilities

With Both Public and Private Health Facilities

Total Without any Health Facilities

Total

Faisalabad 0 2 0 2 167 169

Gujranwala 0 0 0 0 82 82

Lahore 3 0 0 3 353 356

Multan 4 0 0 4 212 216

Rawalpindi 2 0 0 2 74 76

Punjab Total 9 2 0 11 888 899

Table 57: Underserved having Private and Public Health Facilities

Cities With Public Health Facilities

With Private Health Facilities

With Both Public and Private Health Facilities

Total Without any Health Facilities

Total

Faisalabad 0 0 0 0 297 297

Gujranwala 1 4 0 5 160 165

Lahore 0 0 0 0 637 637

Multan 0 0 0 0 104 104

Rawalpindi 0 0 0 0 62 62

Punjab Total 1 4 0 5 1260 1265

Table 58: Slums and Underserved having Private and Public Health Facilities

Cities With Public Health Facilities

With Private Health Facilities

With Both Public and Private Health Facilities

Total Without any Health Facilities

Total

Faisalabad 0 2 0 2 464 466

Gujranwala 1 4 0 5 242 247

Lahore 3 0 0 3 990 993

Multan 4 0 0 4 316 320

Rawalpindi 2 0 0 2 136 138

Punjab Total 10 6 0 16 2148 2164

Table 59: Average Distance between Private Health Facilities and Slums

Cities 0-2km 3km # of Slums Without Private Health Facilities Subtotal

Faisalabad 2 0 167 169

Gujranwala 0 0 82 82

Lahore 0 0 356 356

Multan 0 0 216 216

Rawalpindi 0 0 76 76

Punjab Total 2 0 897 899

Table 60: Average Distance between Private Health Facilities and Underserved

0-2km 3km # of Underserved Without Private Health Facilities Subtotal

Faisalabad 0 0 297 297

Gujranwala 4 0 161 165

Lahore 0 0 637 637

Multan 0 0 104 104

Rawalpindi 0 0 62 62

Punjab Total 4 0 1261 1265

Table 61: Average Distance between Private Health Facilities and Slums/Underserved (Total)

Cities 0-2km 3km # of Slums/Underserved Without Private Health Facilities Subtotal

Faisalabad 2 0 464 466

Gujranwala 4 0 243 247

Lahore 0 0 993 993

Multan 0 0 320 320

Rawalpindi 0 0 138 138

Punjab Total 6 0 2158 2164

77

Table 62: EPI Facilities

Cities

Slums Underserved Areas Slums/Underserved Total

Available Not Available

Available Not Available Available Not Available

Faisalabad 16 153 18 279 34 432

Gujranwala 1 81 7 158 8 239

Lahore 15 341 62 575 77 916

Multan 9 207 6 98 15 305

Rawalpindi 5 71 2 60 7 131

Punjab Total 46 853 95 1170 141 2023

Table 63: Distance Between EPI Facilities and Slums

Cities 0-2km 3km 4km 5+km Slums without EPI facility

Total

Faisalabad 16 0 0 0 153 169

Gujranwala 1 0 0 0 81 82

Lahore 15 0 0 0 341 356

Multan 8 0 0 1 207 216

Rawalpindi 5 0 0 0 71 76

Punjab Total 45 0 0 1 853 899

Table 64: Distance Between EPI Facilities and Underserved (Total)

Cities 0-2km 3km 4km 5+km Slums without EPI facility Total

Faisalabad 18 0 0 0 279 297

Gujranwala 7 0 0 0 158 165

Lahore 62 0 0 0 575 637

Multan 6 0 0 0 98 104

Rawalpindi 2 0 0 0 60 62

Punjab Total 95 0 0 0 1170 1265

Table 65: Distance Between Fixed EPI Facilities in Slums and Underserved (Total)

Cities 0-2km 3km 4km 5+km Slums without EPI facility Total

Faisalabad 34 0 0 0 432 466

Gujranwala 8 0 0 0 239 247

Lahore 77 0 0 0 916 993

Multan 14 0 0 1 305 320

Rawalpindi 7 0 0 0 131 138

Punjab Total 140 0 0 1 2023 2164

Table 66: Outreach of Vaccination Services in Slums

Cities Slums with Outreach Total # of Slums

Faisalabad 109 169

Gujranwala 22 82

Lahore 296 356

Multan 200 216

Rawalpindi 72 76

Table 67: Outreach of Vaccination Services in Underserved

Cities Underserved with Outreach Total Underserved

Faisalabad 189 297

Gujranwala 55 165

Lahore 424 637

Multan 104 104

Rawalpindi 56 62

Punjab Total 828 1265

Table 68: Outreach of Vaccination Services in Slums/Underserved (Total)

Cities Slums/Underserved with Outreach Total Slums/Underserved

Faisalabad 298 466

Gujranwala 77 247

Lahore 720 993

Multan 304 320

Rawalpindi 128 138

Punjab Total 1527 2164

Table 69: Lady Health Worker in Slums

Cities LHWs Covered LHWs Uncovered Total Slums

Faisalabad 31 138 169

Gujranwala 5 77 82

Lahore 222 134 356

Multan 70 146 216

Rawalpindi 33 43 76

Punjab Total 361 538 899

78

Table 70: Lady Health Worker in Underserved

Cities LHWs Covered LHWs Uncovered Total Underserved

Faisalabad 72 225 297

Gujranwala 32 133 165

Lahore 324 313 637

Multan 39 65 104

Rawalpindi 18 44 62

Punjab Total 485 780 1265

Table 71: Lady Health Worker in Slums/Underserved (Total)

Cities LHWs Covered LHWs Uncovered Total Slums/Underserved

Faisalabad 103 363 466

Gujranwala 37 210 247

Lahore 546 447 993

Multan 109 211 320

Rawalpindi 51 87 138

Punjab Total 846 1318 2164

Table 72: Availability of 1122 Services

Cities # of Slums

Slums

# of Underserved

Underserved Areas Slums/Underserved Areas

Slums With 1122

Slums Without 1122

Underserved With 1122

Underserved Without 1122

Slums/Underserved With 1122

Slums/Underserved Without 1122

Faisalabad 169 156 13 297 284 13 440 26

Gujranwala 82 82 0 165 150 15 232 15

Lahore 356 256 100 637 585 52 841 152

Multan 216 213 3 104 103 1 316 4

Rawalpindi 76 76 0 62 62 0 138 0

Punjab Total 899 783 116 1265 1184 81 1967 197

Table 73: Availability of 1038 Services

Cities

Slums

# of Underserved

Underserved Areas Slums/Underserved Areas

# of Slums

Slums With 1038

Slums Without 1038

Underserved With 1038

Underserved Without 1038

Slums/Underserved With 1038

Slums/Underserved Without 1038

Faisalabad 169 6 163 297 7 290 13 453

Gujranwala 82 0 82 165 1 164 1 246

Lahore 356 9 347 637 41 596 50 943

Multan 216 1 215 104 0 104 1 319

Rawalpindi 76 0 76 62 0 62 0 138

Punjab Total

899 16 883 1265 49 1216 65 2099

Table 74: Dengue Workers

Cities

Slums Underserved Slums/Underserved Total

Available Not Available Available Not Available

Available Not Available

Sub Total

Faisalabad 72 97 136 161 208 258 466

Gujranwala 82 0 53 112 135 112 247

Lahore 269 87 527 110 796 197 993

Multan 180 36 97 7 277 43 320

Rawalpindi 76 0 62 0 138 0 138

Punjab Total 679 220 875 390 1554 610 2164

Table 75: Types of Housing Structure in Slums

Cities Kacha or Tented Pacca Kacha-Pacca (Mixed) Total

Faisalabad 7,629 29,458 48,318 85,405

Gujranwala 8,315 26,650 21,344 56,309

Lahore 32,057 84,917 128,443 245,417

Multan 9,255 51,606 43,709 104,570

Rawalpindi 13,186 47,441 29,919 90,546

Punjab Total 70,442 240,072 271,733 582,247

Table 76: Types of Housing Structure in Underserved

Cities Kacha or Tented Pacca Kacha-Pacca (Mixed) Total

Faisalabad 0 135,313 23,934 159,247

Gujranwala 0 141,745 44,663 186,408

Lahore 0 436,371 23,751 460,122

Multan 0 54,966 14,453 69,419

Rawalpindi 0 55,402 18,713 74,115

Punjab Total 0 823,797 125,514 949,311

79

Table 77: Types of Housing Structures in Slums/Underserved (Total)

Cities Kacha or Tented Pacca Kacha-Pacca (Mixed)

Total

Faisalabad 7,629 164,771 72,252 244,652

Gujranwala 8,315 168,395 66,007 242,717

Lahore 32,057 521,288 152,194 705,539

Multan 9,255 106,572 58,162 173,989

Rawalpindi 13,186 102,843 48,632 164,661

Punjab Total 70,442 1,063,869 397,247 1,531,558

Table 78: Sources of Domestic Water in Slums

Cities Government Water Supply

Ground Water (Well, Hand Pump, Tube Well)

Acquire From Other Sources Of Water

Faisalabad 29 125 15

Gujranwala 7 55 20

Lahore 111 118 127

Multan 40 158 18

Rawalpindi 22 38 16

Punjab Total 209 494 196

Table 79: Sources of Domestic Water in Underserved

Cities Government Water Supply Ground Water (Well, Hand Pump, Tube Well) Acquire From Other Sources Of Water

Faisalabad 88 45 164

Gujranwala 23 64 78

Lahore 276 261 100

Multan 28 46 30

Rawalpindi 35 12 15

Punjab Total 450 428 387

Table 80: Sources of Domestic Water in Slums/Underserved (Total)

Cities Government Water Supply Ground Water (Well, Hand Pump, Tube Well) Acquire From Other Sources Of Water

Faisalabad 117 170 179

Gujranwala 30 119 98

Lahore 387 379 227

Multan 68 204 48

Rawalpindi 57 50 31

Punjab Total 659 922 583

Table 81: Duration of Water Availability (in case of Government Water Supply) in Slums

Cities 1-5 hours

6-10 hours

11-15 hours 16-20 hours

20+ hours

Slums without Government Water Supply

Sub Total

Faisalabad 16 11 1 1 0 140 169

Gujranwala 1 5 0 1 0 75 82

Lahore 54 46 6 4 1 245 356

Multan 23 17 0 0 0 176 216

Rawalpindi 20 2 0 0 0 54 76

Punjab Total 114 81 7 6 1 690 899

Table 82: Duration of Water Availability (in case of Government Water Supply) in Underserved

Cities 1-5 hours

6-10 hours

11-15 hours

16-20 hours

20+ hours Slums without Government Water Supply

Sub Total

Faisalabad 41 36 10 1 0 209 297

Gujranwala 6 8 2 3 4 142 165

Lahore 70 119 27 42 18 361 637

Multan 8 20 0 0 0 76 104

Rawalpindi 30 5 0 0 0 27 62

Punjab Total 155 188 39 46 22 815 1265

Table 83: Duration of Water Availability (in case of Government Water Supply) in Slums/Underserved (Total)

Cities 1-5 hours

6-10 hours

11-15 hours

16-20 hours

20+ hours Slums without Government Water Supply

Sub Total

Faisalabad 57 47 11 2 0 349 466

Gujranwala 7 13 2 4 4 217 247

Lahore 124 165 33 46 19 606 993

Multan 31 37 0 0 0 252 320

Rawalpindi 50 7 0 0 0 81 138

Punjab Total 269 269 46 52 23 1505 2164

80

Table 84: Availability of Household Toilets in Slums

Cities # of House Having Toilets # of Household Not Having Toilet Total Household

Faisalabad 83,553 1,852 85,405

Gujranwala 55,549 760 56,309

Lahore 240,881 4,536 245,417

Multan 103,816 754 104,570

Rawalpindi 90,046 500 90,546

Punjab Total 573,845 8,402 582,247

Table 85: Availability of Household Toilet in Underserved

Cities # of House Having Toilets # of Household Not Having Toilet Total Household

Faisalabad 158,273 964 159,237

Gujranwala 185,953 455 186,408

Lahore 457,833 2,289 460,122

Multan 65,209 4,210 69,419

Rawalpindi 74,005 110 74,115

Punjab Total 941,273 8,028 949,301

Table 86: Availability of Household Toilet in Slums/Underserved

Cities # of House Having Toilets # of Household Not Having Toilet Total Household

Faisalabad 241,826 2,816 244,642

Gujranwala 241,502 1,215 242,717

Lahore 698,714 6,825 705,539

Multan 169,025 4,964 173,989

Rawalpindi 164,051 610 164,661

Punjab Total 1,515,118 16,430 1,531,548

Table 87: Type of Household Toilet in Slums

Cities Connected with Street Drain Traditional/Open pit Sub-Total

Faisalabad 45,876 37,677 83,553

Gujranwala 35,485 20,064 55,549

Lahore 152,361 88,520 240,881

Multan 53,970 49,846 103,816

Rawalpindi 40,111 49,935 90,046

Punjab Total 327,803 246,042 573,845

Table 88: Type of Household Toilet in Underserved

Cities Connected with Street Drain Traditional/Open pit Sub-Total

Faisalabad 101,536 56,737 158,273

Gujranwala 129,287 56,666 185,953

Lahore 191,119 266,714 457,833

Multan 25,898 39,311 65,209

Rawalpindi 26,847 47,158 74,005

Punjab Total 474,687 466,586 941,273

Table 89: Type of Household Toilet in Slums/Underserved (Total)

Cities Connected with Street Drain Traditional/Open pit Sub-Total

Faisalabad 147,412 94,414 241,826

Gujranwala 164,772 76,730 241,502

Lahore 343,480 355,234 698,714

Multan 79,868 89,157 169,025

Rawalpindi 66,958 97,093 164,051

Punjab Total 802,490 712,628 1,515,118

Table 90: Average # of People using Toilet

Cities Average # of People Using Toilet

Faisalabad 6

Gujranwala 5

Lahore 6

Multan 7

Rawalpindi 7

Punjab Total 6

Table 91: Average # of People using Toilet in Underserved

Cities Average # of People Using Toilet

Faisalabad 6

Gujranwala 7

Lahore 7

Multan 7

Rawalpindi 8

Punjab Total 7

81

Table 92: Average # of People using Toilet in Slums and Underserved Areas (Total)

Cities Average # of People Using Toilet

Faisalabad 6

Gujranwala 6

Lahore 7

Multan 7

Rawalpindi 7

Punjab Total 7

Table 93: Modes of Defecation Without Toilet in Slums

Cities Neighbor’s Toilets Public Toilet Open Defecation Not Applicable Sub-Total

Faisalabad 0 0 21 148 169

Gujranwala 0 1 8 73 82

Lahore 0 0 43 313 356

Multan 1 2 6 207 216

Rawalpindi 0 1 7 68 76

Punjab Total 1 4 85 809 899

Table 94: Modes of Defecation Without Toilet in Underserved

Cities Neighbor’s Toilets Public Toilet Open Defecation Not Applicable Sub-Total

Faisalabad 0 0 18 279 297

Gujranwala 0 0 4 161 165

Lahore 0 0 18 619 637

Multan 0 0 2 102 104

Rawalpindi 0 1 2 59 62

Punjab Total 0 1 44 1220 1265

Table 95: Modes of Defecation Without Toilet in Slums/Underserved (Total)

Cities Neighbor’s Toilets Public Toilet Open Defecation Not Applicable Sub-Total

Faisalabad 0 0 39 427 466

Gujranwala 0 1 12 234 247

Lahore 0 0 61 932 993

Multan 1 2 8 309 320

Rawalpindi 0 2 9 127 138

Punjab Total 1 5 129 2029 2164

Table 96: Condition of Drains in Slums

Cities Drains Have Running Water Drains Are Filthy/Choked # Of Areas With No Drains

Sub-Total

Faisalabad 32 92 45 169

Gujranwala 14 38 30 82

Lahore 94 142 120 356

Multan 55 122 39 216

Rawalpindi 45 20 11 76

Punjab Total 240 414 245 899

Table 97: Condition of Drains in Underserved

Cities Drains Have Running Water Drains Are Filthy/Choked # Of Areas With No Drains Sub-Total

Faisalabad 79 170 48 297

Gujranwala 25 91 49 165

Lahore 65 239 333 637

Multan 22 45 37 104

Rawalpindi 23 31 8 62

Punjab Total 214 576 475 1265

Table 98: Condition of Drains in Slums and Underserved (Total)

Cities Drains have running water Drains are filthy/choked # of Areas with no drains Sub-Total

Faisalabad 111 262 93 466

Gujranwala 39 129 79 247

Lahore 159 381 453 993

Multan 77 167 76 320

Rawalpindi 68 51 19 138

Punjab Total 454 990 720 2164

Table 99: Solid Waste Disposal Practices in Slums

Cities Govt/WMC vehicle Other Systems Dumping on Empty Plot and Street Total

Faisalabad 48 6 115 169

Gujranwala 11 4 67 82

Lahore 169 4 183 356

Multan 80 3 133 216

Rawalpindi 26 0 50 76

Punjab Total 334 17 548 899

82

*Note: The option of other includes burnt and buried

Table 100: Solid Waste Disposal Practices in Underserved

Cities Govt/WMC vehicle Other Systems Dumping on Empty Plot and Street Total

Faisalabad 129 14 154 297

Gujranwala 33 14 118 165

Lahore 458 12 167 637

Multan 55 1 48 104

Rawalpindi 41 2 19 62

Punjab Total 716 43 506 1265

Table 101: Solid Waste Disposal Practices in Slums and Underserved (Total)

Cities Govt/WMC vehicle Other Systems Dumping on Empty Plot and Street Total

Faisalabad 177 20 269 466

Gujranwala 44 18 185 247

Lahore 627 16 350 993

Multan 135 4 181 320

Rawalpindi 67 2 69 138

Punjab Total 1050 60 1054 2164

Table 102: Schools in Slums and Underserved

Cities

Slums Underserved Areas

Available Not Available Total Slums Available Not Available Total Underserved

Faisalabad 106 63 169 221 76 297

Gujranwala 57 25 82 98 67 165

Lahore 276 80 356 518 119 637

Multan 172 44 216 86 18 104

Rawalpindi 45 31 76 51 11 62

Punjab Total 656 243 899 974 291 1265

Table 103: Schools in Slums and Underserved (Total)

Cities # of Areas With Schools # of Areas Without Schools Total slums/Underserved

Faisalabad 327 139 466

Gujranwala 155 92 247

Lahore 794 199 993

Multan 258 62 320

Rawalpindi 96 42 138

Punjab Total 1630 534 2164

Table 104: Types of Schools in Slums

Cities Government Private Welfare/Trust Maktab/Madrsa Other No Schools

Faisalabad 55 84 9 51 2 63

Gujranwala 32 27 0 6 0 25

Lahore 187 204 19 89 0 80

Multan 140 122 4 48 1 44

Rawalpindi 27 31 10 19 0 31

Punjab Total 441 468 42 213 3 243

Table 105: Types of Schools in Underserved

Cities Government Private Welfare/Trust Maktab/Madrsa Other No Schools

Faisalabad 112 194 27 111 1 76

Gujranwala 53 52 2 12 0 67

Lahore 293 426 41 230 1 119

Multan 61 69 6 33 0 18

Rawalpindi 32 41 6 19 0 11

Punjab Total 551 782 82 405 2 291

Table 106: Types of Schools in Slums and Underserved Areas (Total)

Cities Government Private Welfare/Trust Maktab/Madrsa Other No Schools

Faisalabad 167 278 36 162 3 139

Gujranwala 85 79 2 18 0 92

Lahore 480 630 60 319 1 199

Multan 201 191 10 81 1 62

Rawalpindi 59 72 16 38 0 42

Punjab Total 992 1250 124 618 5 534

83

Table 107: Distance of Nearest School from Slums

Cities 0-2km 3km 4km 5+km Slums Without schools Sub Total

# # # # # #

Faisalabad 103 3 0 0 63 169

Gujranwala 57 0 0 0 25 82

Lahore 276 0 0 0 80 356

Multan 171 0 1 0 44 216

Rawalpindi 44 0 0 1 31 76

Punjab Total 651 3 1 1 243 899

Table 108: Distance of Nearest School from Underserved

Cities 0-2km 3km 4km 5+km Slums Without schools Sub Total

Faisalabad 221 0 0 0 76 297

Gujranwala 97 1 0 0 67 165

Lahore 505 9 0 4 119 637

Multan 84 2 0 0 18 104

Rawalpindi 51 0 0 0 11 62

Punjab Total 958 12 0 4 291 1265

Table 109: Distance of Nearest School and Slums/Underserved

0-2km 3km 4km 5+km Slums Without schools Sub Total

Faisalabad 324 3 0 0 139 466

Gujranwala 154 1 0 0 92 247

Lahore 781 9 0 4 199 993

Multan 255 2 1 0 62 320

Rawalpindi 95 0 0 1 42 138

Punjab Total 1609 15 1 5 534 2164

Table 110: Availability of Working by CSOs

Cities Slums Underserved Areas Slum/Underserved Areas

Available Not Available Available Not Available Available Not Available

Faisalabad 2 167 13 284 15 451

Gujranwala 0 82 2 163 2 245

Lahore 10 346 28 609 38 955

Multan 0 216 1 103 1 319

Rawalpindi 3 73 1 61 4 134

Punjab Total 15 884 45 1220 60 2104

Table 111: Types of Services by CSOs in Slums

Types of Services Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total

Education 1 0 2 0 1 4

Health 0 0 4 0 1 5

Human Rights 0 0 3 0 0 3

(Micro Loans) 1 0 1 0 0 2

Water 0 0 0 0 1 1

Areas with no charity organization 167 82 346 216 73 884

Total 169 82 356 216 76 899

Table 112: Types of Services by CSOs in Underserved Areas

Types of Services Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total

Education 12 0 15 0 0 27

Health 0 1 6 1 1 9

Human Rights 0 1 6 0 0 7

Loans 0 0 1 0 0 1

Water 1 0 0 0 0 1

No CSO 284 163 609 103 61 1220

Grand Total 297 165 637 104 62 1265

Table 113: Types of Services by CSOs in Slums/Underserved Areas (Total)

Types of Services Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total

Education 13 0 17 0 1 31

Health 1 1 10 1 2 14

Human Rights 0 1 9 0 1 10

Loans 1 0 2 0 0 3

Water 1 0 0 0 0 2

No CSO 453 245 955 319 134 2104

Grand Total 466 247 993 320 138 2164

84

Table 114: Presence of Informal Groups

Cities Slums Underserved Slum/Underserved (Total)

Available Not Available Available Not Available Available Not Available

Faisalabad 56 113 117 180 173 293

Gujranwala 26 56 36 129 62 185

Lahore 138 218 275 362 413 580

Multan 86 130 33 71 119 201

Rawalpindi 43 33 39 23 82 56

Punjab Total 349 550 500 765 849 1315

Grand Total 566 1213 516 819 1082 2032

Table 115: Type of Informal Groups in Slums

Types of Informal Groups Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total

Health Committee 5 5 62 12 0 84

Jirga/Punchaiyat 0 1 3 1 4 9

Masjid/Church Committee 34 15 43 37 27 156

School Committee 0 0 1 4 0 5

Unregistered Community-Based Organization 5 0 1 12 6 24

Zakat Committee 12 5 28 20 6 71

No Informal Groups or Committees 113 56 218 156 33 581

Total 169 82 356 216 76 899

Table 116: Types of Informal Groups in Underserved Areas

Types of Informal Groups Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total

Health Committee 1 0 18 0 1 20

Jirga/Punchaiyat 1 2 3 0 0 6

Masjid/ChurchCommittee 76 26 87 24 34 247

School Committee 0 0 0 0 0 0

Unregistered Community-Based Organization

0 0 75 1 0 76

Zakat Committee 39 8 92 8 4 151

No Informal Groups or Committees 180 129 362 71 23 765

Grand Total 297 165 637 104 62 1265

Table 117: Types of Informal Groups in Slums/Underserved Areas

Types of Informal Groups Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total

Health Committee 6 5 80 12 1 104

Jirga/Punchaiyat 1 3 6 1 4 15

Masjid/Church Committee 110 41 130 61 61 403

School Committee 0 0 1 4 0 5

Unregistered Community-Based Organization

5 0 76 13 6 100

Zakat Committee 51 13 120 28 10 222

No Informal Groups or Committees 293 185 580 227 56 1346

Grand Total 466 247 993 320 138 2164

Table 118: Availability of Welfare Scheme by Government

Cities

Slums Underserved Areas Slums/Underserved

Total Slums

Covered Uncovered Total Underserved

Covered Uncovered Total slums/Underserved

Covered Uncovered

Faisalabad 169 56 113 297 136 161 466 192 274

Gujranwala 82 40 42 165 97 68 247 137 110

Lahore 356 145 211 637 512 125 993 657 336

Multan 216 80 136 104 28 76 320 108 212

Rawalpindi 76 29 47 62 22 40 138 51 87

Punjab Total

899 350 549 1265 795 470 2164 1145 1019

85

Table 119: Types of Welfare Schemes by Government

Cities Type of work Loan Scheme Stipend Scheme

Social Benefit Card

Vocational Skills Scheme

Other

Yes No Yes No Yes No Yes No Yes No

Faisalabad

Slum 10 0 4 1 40 3 2 2 0 4

Underserved 15 0 20 2 101 2 0 2 0 2

Gujranwala

Slum 13 2 5 2 20 2 1 1 1 1

Underserved 6 8 20 8 60 8 6 2 5 4

Lahore Slum 15 1 30 2 100 1 0 2 0 2

Underserved 82 7 78 11 345 15 5 15 2 20

Multan Slum 4 2 14 2 60 1 2 2 0 4

Underserved 1 2 1 2 24 2 2 1 0 3

Rawalpindi

Slum 1 1 7 1 20 2 1 1 0 2

Underserved 2 0 2 0 18 0 0 0 0 0

Punjab Total

Slum 43 6 60 8 240 9 6 8 1 13

Underserved 106 17 121 23 548 27 13 20 7 29

Total 149 23 181 31 788 36 19 28 8 42

86

Annex 6: Analysis of Health Resources of Union Councils Table 120: Town Wise Number of UCs with/ without Slums/ Underserved

Faisalabad

Town Total UCs

Iqbal Town 28

Jinnah Town 30

Laylpur Town 22

Madina Town 33

Total 113

Gujranwala

Town Total UCs

Aroop 17

Khaili Shah Pur 13

Nandipur 15

Qila Didar Singh 19

Total 64

Lahore

Town Total UCs

Allama Iqbal 20

Aziz Bhatti 13

Cantt 15

Data Gunj Bukhsh 18

Gulberg 15

Nishter 18

Ravi 19

Samanabad 19

Shalamar 17

Wagha 12

Total 166

Multan

Town Total UCs

Bosan 10

Mumtazabad 13

Shah Rukn-e-Alam 15

Sher Shah 12

Total 50

Rawalpindi

Town Total UCs

Cantt 1

Rawal 45

Potohar 14

Total 60

Table 121: Status of Slums/Underserved in Union Councils

Cities UCs with Slums/Underserved UCs without Slums/Underserved Total

Faisalabad 86 27 113

Gujranwala 58 6 64

Lahore 127 39 166

Multan 36 14 50

Rawalpindi 44 16 60

Total 351 102 453

Table 122: Town wise Number of UCs and Population

Faisalabad

Town Total UCs Population

Iqbal Town 28 710089

Jinnah Town 30 766943

Laylpur Town 22 551786

Madina Town 33 879567

Total 113 2908385

Gujranwala

Aroop 17 452563

Khaili Shah Pur 13 430561

Nandipur 15 345407

Qila Didar Singh 19 415233

Total 64 1643764

Lahore

Allama Iqbal 20 1424271

Aziz Bhatti 13 705344

Cantt 15 897475

Data Gunj Bukhsh 18 772646

87

Gulberg 15 667087

Nishter 18 1226667

Ravi 19 1079025

Samanabad 19 936732

Shalamar 17 929103

Wagha 12 791224

Total 166 9429574

Multan

Bosan 10 316403

Mumtazabad 13 471800

Shah Rukn-e-Alam 15 504565

Sher Shah 12 375673

Total 50 1668441

Rawalpindi

Cantt 1 32550

Rawal 45 1054651

Potohar 14 604718

Total 60 1691919

Table 123: Population of UCs

Cities Population

Faisalabad 2,908,385

Gujranwala 1,643,764

Lahore 9,429,574

Multan 1,668,441

Rawalpindi 1,691,919

Total 17,342,083

Table 124: Number of Health Facilities in UCs

Cities Health Facilities in Total UCs

Faisalabad 52

Gujranwala 29

Lahore 217

Multan 45

Rawalpindi 32

Total 375

Table 125: UCs with/ without Health Facilities

Cities # of UCs with Health Facilities # of UCs without Health Facilities

Faisalabad 52 61 113

Gujranwala 19 45 64

Lahore 160 6 166

Multan 34 16 50

Rawalpindi 28 32 60

Total 293 160 453

Table 126: Number of EPI Facilities

Cities Public EPI Facilities

Faisalabad 67

Gujranwala 18

Lahore 220

Multan 45

Rawalpindi 29

Total 379

Table 127: UCs with/ without EPI Facilities

Cities # of UCs with EPI Facilities # of UCs without EPI Facilities Total

Faisalabad 62 51 113

Gujranwala 18 46 64

Lahore 165 1 166

Multan 34 16 50

Rawalpindi 29 31 60

Total 308 145 453

Table 128: Availability of Functional ILR/Refrigerator in Fixed EPI Facility

Cities EPIs with Functional ILR EPIs without Functional ILR Total

Faisalabad 67 0 67

Gujranwala 18 0 18

Lahore 220 0 220

Multan 45 0 45

Rawalpindi 27 2 29

Total 377 2 379

88

Table 129: Outreach Vaccination Services

Cities UCs with Outreach Vaccination Total UCs

Faisalabad 113 113

Gujranwala 64 64

Lahore 166 166

Multan 50 50

Rawalpindi 60 60

Total 453 453

Table 130: Nutrition Services

Cities Available in UCs Not Available in UCs Total

Faisalabad 63 50 113

Gujranwala 19 45 64

Lahore 166 0 166

Multan 34 16 50

Rawalpindi 28 32 60

Total 310 143 453

Table 131: Types of Nutrition Services in UCs

Cities Fixed Temporary Sites School Session Sessions by LHWs No Nutrition Services

Faisalabad 63 0 0 0 50

Gujranwala 19 0 0 0 45

Lahore 12 0 22 144 0

Multan 34 0 0 0 16

Rawalpindi 28 0 0 28 32

Total 156 0 22 172 143

Table 132: Number of Vaccinators in Public Health Facilities

Cities Total EPI Facilities Total Vaccinators

Faisalabad 67 75

Gujranwala 18 19

Lahore 220 356

Multan 45 45

Rawalpindi 29 29

Total 379 524

Table 133: Number of UCs Covered by LHWs

Cities UCs Covered by LHWs UCs Uncovered by LHWs Total UCs Total Number of LHWs

Faisalabad 69 44 113 173

Gujranwala 55 9 64 64

Lahore 163 3 166 1335

Multan 42 8 50 265

Rawalpindi 29 31 60 135

Total 358 95 453 1,972

Table 134: Availability of Dengue Workers

Cities Dengue Workers Available in UCs Dengue Workers not Available in UCs Total UCs

Faisalabad 113 0 113

Gujranwala 64 0 64

Lahore 166 0 166

Multan 50 0 50

Rawalpindi 60 0 60

Total 453 0 453

89

Annex 7: Analysis of Results of EPI Facility Assessment Table 135: Number of EPI Facilities

Names of Towns Number of UCs UCs with EPI Facilities Number of EPI Facilities

Faisalabad

Iqbal Town 28 17 9

Jinnah Town 30 22 0

Laylpur Town 22 19 11

Madina Town 33 28 14

Total 113 86 34

Gujranwala

Aroop 17 16 3

Khaili Shah Pur 13 13 4

Nandipur Town 15 11 5

Qila Didar Singh 19 18 6

Total 64 58 18

Lahore

Allama Iqbal 20 20 20

Aziz Bhatti 13 12 11

Cantt 15 1 0

Data Gunj Bukhsh 18 15 18

Gulberg 15 14 15

Nishter 18 15 19

Ravi 19 18 15

Samanabad 19 15 11

Shalamar 17 14 13

Wagha 12 3 5

Total 166 127 127

Multan

Bosan Town 10 4 4

Mumtaz abad 13 10 8

Shah Rukn Alam 15 13 12

Sher Sha 12 9 6

Total 50 36 30

Rawalpindi

Cantt 1 1 0

Rawal 45 32 10

Potohar 14 11 9

Total 60 44 19

Table 136: Status of Ownership of Building of EPI Facilities

City Owned Rented Total

Faisalabad 34 0 34

Gujranwala 9 9 18

Lahore 120 7 127

Multan 17 13 30

Rawalpindi 19 0 19

Sub Total 199 29 228

Table 137: Types of EPI Facilities

City Government Private Charity Total

Faisalabad 34 0 0 34

Gujranwala 18 0 0 18

Lahore 120 7 0 127

Multan 30 0 0 30

Rawalpindi 19 0 0 19

Total 221 7 0 228

Note: There is 1 EPI Centre Other than mentioned variables

Table 138: Average Working Hours of EPI Facilities

City Less than 6 Hours 6 Hours Total

Faisalabad 0 34 34

Gujranwala 1 17 18

Lahore 2 125 127

Multan 0 30 30

Rawalpindi 1 18 19

Total 4 224 228

90

Table 139: Availability of Standard Operating Procedures

City Available Not Available Total

Faisalabad 27 7 34

Gujranwala 2 16 18

Lahore 62 65 127

Multan 10 20 30

Rawalpindi 7 12 19

Total 108 120 228

Table 140: Availability of LHVs in EPI Facilities

City Available Not Available Total Total # of LHVs

Faisalabad 26 8 34 31

Gujranwala 4 14 18 5

Lahore 72 55 127 81

Multan 18 12 30 21

Rawalpindi 14 5 19 20

Total 134 94 228 158

LHVs are deployed according to the status of health facility. If some facilities offer only vaccination services then LHVs are not deployed there as per government system.

Table 141: Availability of Vaccinators in EPI Facilities

City Available Not Available Total Total # of Vaccinators

Faisalabad 34 0 34 40

Gujranwala 18 0 18 23

Lahore 127 0 127 225

Multan 30 0 30 31

Rawalpindi 19 0 19 19

Total 228 0 228 338

Table 142: Vaccine Supplies

Cities

Availability of Types of Vaccine Supplies

Auto Disable Syringes Safety Boxes/ Sharp Containers

Vaccine Carrier (s)

Icepacks

Faisalabad 34 34 34 34

Gujranwala 17 18 18 18

Lahore 127 127 124 125

Multan 30 30 30 27

Rawalpindi 15 19 17 17

Total 223 228 223 221

Table 143: Supply of Vaccines

City Infrequent Shortage Frequent Shortage No Shortage Total

Faisalabad 1 0 33 34

Gujranwala 15 0 3 18

Lahore 0 0 127 127

Multan 0 0 30 30

Rawalpindi 0 0 19 19

Total 16 0 212 228

Table 144: Availability of Ice Lined Refrigerators

City Available Functional Available Non-Functional Not Available Total

Faisalabad 34 0 0 34

Gujranwala 18 0 0 18

Lahore 127 0 0 127

Multan 30 0 0 30

Rawalpindi 17 2 0 19

Total 226 2 0 228

Table 145: Availability of Waiting Areas

City Gender Mixed Waiting Area Gender Segregated Waiting Area Total

Faisalabad 22 12 34

Gujranwala 14 4 18

Lahore 93 34 127

Multan 12 18 30

Rawalpindi 8 11 19

Total 149 79 228

91

Table 146: Seating Capacity of Waiting Areas in EPI Facilities

City Adequate Inadequate Total

Faisalabad 21 13 34

Gujranwala 10 8 18

Lahore 80 47 127

Multan 21 9 30

Rawalpindi 13 6 19

Total 145 83 228

Note: 12 EPI Facilities having no waiting areas

Table 147: Availability of Drinking Water

City Available Not Available Total

Faisalabad 30 4 34

Gujranwala 5 13 18

Lahore 74 53 127

Multan 17 13 30

Rawalpindi 16 3 19

Total 142 86 228

Table 148: Availability of Toilets

City Gender Segregated Available Gender Mixed Available Not Available Total

Faisalabad 11 23 0 34

Gujranwala 3 8 7 18

Lahore 50 32 45 127

Multan 15 5 10 30

Rawalpindi 9 2 8 19

Total 88 70 70 228

Table 149: Usability of Toilet

Cities Useable Not Useable Toilet Not Available Total

Faisalabad 32 2 0 34

Gujranwala 8 3 7 18

Lahore 72 10 45 127

Multan 14 6 10 30

Rawalpindi 11 0 8 19

Total 137 21 70 228

Table 150: Waste Management Practices

City Buries/Burnt WMC Vehicle Total

Faisalabad 34 0 34

Gujranwala 18 0 18

Lahore 124 3 127

Multan 24 6 30

Rawalpindi 19 0 19

Total 219 9 228

92

Annex 8: Analysis of Household Coverage Survey

Table 151: Sample Size

Cities Households Mothers Children

Faisalabad 708 712 716

Gujranwala 918 918 918

Lahore 820 820 820

Multan 582 582 583

Rawalpindi 824 824 826

Total 3852 3856 3863

Table 152: Gender Wise Total Children

Cities Boys Girls Total

Faisalabad 404 312 716

Gujranwala 487 431 918

Lahore 449 371 820

Multan 336 247 583

Rawalpindi 441 385 826

Total 2117 1746 3863

Table 153: Number of Children of Each Mother of Less Than 2 Year of Age

Cities 1 2 3 Total

Faisalabad 708 4 0 712

Gujranwala 918 0 0 918

Lahore 820 0 0 820

Multan 581 1 0 582

Rawalpindi 822 2 0 824

Total 3849 7 0 3856

Table 154: Total Family Members with Gender Segregation

Cities Total Household members Male Female

Faisalabad 6192 3097 3095

Gujranwala 5888 2882 3006

Lahore 5298 2740 2558

Multan 3625 1808 1817

Rawalpindi 5883 2838 3045

Total 26886 13365 13521

Table 155: Average Family Size

Cities Average Family Size Average Male Members Average Female Members

Faisalabad 9 5 4

Gujranwala 6 3 3

Lahore 6 3 3

Multan 6 3 3

Rawalpindi 7 3 4

Total 34 17 17

Table 156: Children with/without Vaccination Card

Cities With Card (Records) Without Card (Recall) Zero Dose Total Children

Male Female Total Male Female Total

Faisalabad 216 156 372 146 131 277 67 716

Gujranwala 316 285 601 59 41 100 217 918

Lahore 257 224 481 95 77 172 167 820

Multan 226 152 378 85 73 158 47 583

Rawalpindi 261 247 508 92 77 169 149 826

Total 1276 1064 2340 477 399 876 647 3863

Table 157: Fully Immunized Children (Records + Recall)

Cities Total Eligible Children # of Fully Immunized Children Male Female

Faisalabad 716 405 232 173

Gujranwala 918 593 319 274

Lahore 820 437 236 201

Multan 583 446 259 187

Rawalpindi 826 567 303 264

Total 3863 2448 1349 1099

93

Table 158: Fully Immunized Children (Records)

Cities Total Eligible Children # of Fully Immunized Children Male Female

Faisalabad 716 259 147 112

Gujranwala 918 527 279 248

Lahore 820 386 207 179

Multan 583 320 192 128

Rawalpindi 826 427 224 203

Total 3863 1919 1049 870

Table 159: Antigen Wise Coverage (Records + Recall)

Cities Total Eligible Children

BCG Penta 1 Penta 2 Penta 3 Measles 1 Measles 2

Faisalabad 716 647 633 587 537 415 342

Gujranwala 918 700 685 647 638 594 378

Lahore 820 645 595 552 507 456 407

Multan 583 536 530 516 487 459 330

Rawalpindi 826 671 667 661 635 587 368

Total 3863 3199 3110 2963 2804 2511 1825

Table 160: Antigen Wise Coverage (Records)

Cities Total Eligible Children

BCG Penta 1 Penta 2 Penta 3 Measles 1 Measles 2

Faisalabad 716 370 368 363 358 261 197

Gujranwala 918 601 597 577 568 528 312

Lahore 820 473 468 454 431 401 357

Multan 583 378 376 369 340 327 249

Rawalpindi 826 503 500 494 479 438 284

Total 3863 2325 2309 2257 2176 1955 1399

Table 161: Partially Vaccinated Children (Records+ Recall)

Cities FI (Records +Recall) ZD Partially Vaccinated

Faisalabad 405 67 244

Gujranwala 593 217 108

Lahore 437 167 216

Multan 446 47 90

Rawalpindi 567 149 110

Total 2448 647 768

Table 162: Gender of Partially Vaccinated Children on Record and Recall Basis

Cities Male Female Total

Faisalabad 130 114 244

Gujranwala 56 52 108

Lahore 116 100 216

Multan 52 38 90

Rawalpindi 50 60 110

Total 404 364 768

Table 164: Status of Zero Dose Children

Cities Zero Dose

Male Female Total

Faisalabad 42 25 67

Gujranwala 112 105 217

Lahore 97 70 167

Multan 25 22 47

Rawalpindi 88 61 149

Total 364 283 647

Table 163: Partially Vaccinated Children (Records)

Cities FI (Records) With Card Partially Vaccinated

Faisalabad 259 372 113 16%

Gujranwala 527 601 74 8%

Lahore 386 481 95 12%

Multan 320 378 58 10%

Rawalpindi 427 508 81 10%

Total 1919 2340 421 11%

94

Table 165: Reasons of Zero Dose Children

Reasons for Zero Dose FSD GUJ LHR MTN RWP

Mother Number of Zero Dose 67 217 167 47 149

Vaccination causes more diseases 7 16 97 7 34

Unavailability of Time for Vaccination/Wastage of time 11 96 14 4 23

Unaware of EPI/ outreach Centre 5 1 2 0 15

Unaware of Vaccination Timings 5 25 1 0 7

No Family Permission 10 11 21 4 25

Fear of Injection 28 49 32 31 41

Transport cost to EPI facility is High 0 2 0 1 0

Environment in EPI facility is not good 0 4 0 0 0

Unaware of Childhood Vaccination 4 14 0 0 5

Child Was Sick 0 0 0 0 0

No Facility Available 0 0 0 0 0

Total 137 435 334 94 299

Table 166: Perception of Mothers about Purpose of Vaccination of Children

Cities To Protect from Disease Other Purpose Do Not Know Total

Faisalabad 440 203 69 712

Gujranwala 477 115 326 918

Lahore 386 243 191 820

Multan 379 133 70 582

Rawalpindi 405 200 219 824

Total 2087 894 875 3856

Table 167: Knowledge of Mothers About Working of LHWs

Cities Mothers having knowledge Mothers not having knowledge Total

Faisalabad 433 61% 279 39% 712 100%

Gujranwala 99 11% 819 89% 918 100%

Lahore 591 72% 229 28% 820 100%

Multan 552 95% 30 5% 582 100%

Rawalpindi 622 75% 202 25% 824 100%

Total 2297 60% 1559 40% 3856 100%

Table 168: Types of Services Provided by LHWs (Perception of Mothers)

Cities Promote Health Education

Supply Family Planning Products

Refer to Hospital

Information About Immunization

Give Guidance about treatment of illness

Help Vaccinator

Don’t Know

Not Applicable

Total

Faisalabad 363 40 0 0 0 0 30 279 712

Gujranwala 58 37 4 0 0 0 0 819 918

Lahore 510 28 0 52 0 0 0 230 820

Multan 447 58 47 0 0 0 0 30 582

Rawalpindi 529 62 31 0 0 0 0 202 824

Total 1907 225 82 52 0 0 30 1560 3856

Table 169: Preferred Channels of Communication for Mothers

Cities T.V Radio Poster/Billboard Leaflet Health Worker Others

Faisalabad 605 117 184 51 356 49

Gujranwala 339 35 50 11 93 378

Lahore 653 153 302 115 245 135

Multan 480 298 377 211 377 143

Rawalpindi 648 313 267 221 404 152

Total 2725 916 1180 609 1475 857

Table 170: Age Range of Mothers Surveyed

Cities 14-19 20-24 25-29 30-34 35-39 40+ Total

Faisalabad 9 119 237 257 83 7 712

Gujranwala 11 175 354 261 107 10 918

Lahore 15 146 393 206 49 11 820

Multan 12 109 234 164 53 10 582

Rawalpindi 20 128 334 227 100 15 824

Total 67 677 1552 1115 392 53 3856

95

Table 171: Years of Schooling Completed by Mothers

Cities 0 1-5 6-10 11-15 15+ Total

# # # # # #

Faisalabad 224 155 254 65 14 712

Gujranwala 160 211 395 131 21 918

Lahore 419 90 235 68 8 820

Multan 184 148 187 63 0 582

Rawalpindi 367 119 202 109 27 824

Total 1354 723 1273 436 70 3856

Table 172: Engagement of Mothers in Livelihood Activities

Cities Yes No Total

Faisalabad 13 699 712

Gujranwala 38 880 918

Lahore 35 785 820

Multan 52 530 582

Rawalpindi 26 798 824

Total 164 3692 3856

Table 173: Commonly Spoken Languages

Cities Urdu Punjabi Potohari Balochi Pashto Sindhi Siraiki Others Total

Faisalabad 5 685 0 0 3 0 15 0 708

Gujranwala 302 604 1 1 10 0 0 0 918

Lahore 142 587 0 1 51 1 8 30 820

Multan 93 205 0 0 6 0 277 1 582

Rawalpindi 149 475 11 4 129 3 41 12 824

Total 691 2556 12 6 199 4 341 43 3852

Table 174: Housing Structures

Cities Kacha Kacha-Pacca Pacca Total

Faisalabad 70 259 379 708

Gujranwala 113 203 602 918

Lahore 175 135 510 820

Multan 90 63 429 582

Rawalpindi 135 177 512 824

Total 583 837 2432 3852

Total 583 837 2432 3852

Table 175: Number of Rooms per House

Cities 1 Room 2-3 Rooms 4-6 Rooms 7-10 Rooms 10+ Rooms

Total

Faisalabad 175 455 73 5 0 708

Gujranwala 95 633 183 7 0 918

Lahore 365 400 51 4 0 820

Multan 114 413 55 0 0 582

Rawalpindi 158 539 116 10 1 824

Total 907 2440 478 26 1 3852

Table 176: Availability of Electricity

Cities Houses With Electricity Houses Without Electricity Total

Faisalabad 688 20 708

Gujranwala 896 22 918

Lahore 740 80 820

Multan 565 17 582

Rawalpindi 781 43 824

Total 3670 182 3852

Table 177: Sources of Water

Cities Government Water Supply Ground Water Acquire Water Total

Faisalabad 107 513 88 708

Gujranwala 15 712 191 918

Lahore 498 299 23 820

Multan 217 361 4 582

Rawalpindi 322 389 113 824

Total 1159 2274 419 3852

96

Table 178: Duration of Water Availability in Case of Government Water Supply

Cities Less than 1 hour

1-5 hours 6-10 hours 11-15 hours

16-20 hours 20+ Hours

Total

Faisalabad 0 88 18 0 0 1 107

Gujranwala 0 9 6 0 0 0 15

Lahore 0 219 207 54 16 2 498

Multan 0 139 78 0 0 0 217

Rawalpindi 0 317 5 0 0 0 322

Total 0 772 314 54 16 3 1159

Table 179: Household Toilets

Cities Connected with Street Drains Traditional Latrine/ Open Pit Houses Without Toilets Total

Faisalabad 166 495 47 708

Gujranwala 560 340 18 918

Lahore 393 343 84 820

Multan 425 151 6 582

Rawalpindi 465 287 72 824

Total 2009 1616 227 3852

Table 180: Average Users of One Toilet

Cities Average Toilets Users

Faisalabad 8

Gujranwala 5

Lahore 5

Multan 6

Rawalpindi 6

Table 181: Modes of Defecation in the Case of Unavailability of Household Toilet

Cities Neighbor’s Toilet Public Toilet Open Defecation Houses with Toilets Total

Faisalabad 3 0 44 661 708

Gujranwala 0 1 17 900 918

Lahore 0 1 83 736 820

Multan 0 1 5 576 582

Rawalpindi 1 8 63 752 824

Total 4 11 212 3625 3852

Table 182: Major Professions

Cities Job (Government Job, Private Job, Work in Foreign Country)

Small Business Daily Wage Labor Total

Faisalabad 98 172 438 708

Gujranwala 322 174 422 918

Lahore 226 197 397 820

Multan 170 177 235 582

Rawalpindi 283 153 388 824

Total 1099 873 1880 3852

Table 183: Status of Financial Debt/Savings

Cities Debt (Always / Occasional) No Debt, No Savings Savings Total

Faisalabad 399 293 16 708

Gujranwala 460 235 223 918

Lahore 453 277 90 820

Multan 254 234 94 582

Rawalpindi 383 392 49 824

Total 1949 1431 472 3852

Background Characteristics of Zero Dose Children

Table 184: Education Level of Mothers of Zero Dose Children

Cities 0 (Illiterate) 01—05 06—10 11—15 Total

Faisalabad 41 16 5 5 67

Gujranwala 40 55 107 15 217

Lahore 153 6 7 1 167

Multan 17 16 13 1 47

Rawalpindi 117 16 16 0 149

Total 368 109 148 22 647

97

Table 185: Major Professions of Caregivers of Zero Dose Children

Cities Job Holders Small Business Daily wage Labor Other Total

Faisalabad 4 6 57 0 67

Gujranwala 69 35 113 0 217

Lahore 20 18 128 1 167

Multan 7 15 25 0 47

Rawalpindi 27 21 101 0 149

Total 127 95 424 1 647

Table 186: Status of Financial Debt/Savings in Households of Zero Dose Children

Cities Debt (Always / Occasional) No Debt, No Savings Savings Total

Faisalabad 52 15 0 67

Gujranwala 99 67 51 217

Lahore 88 62 17 167

Multan 22 23 2 47

Rawalpindi 85 62 2 149

Total 346 229 72 647

Table 187: Family Sizes of Zero Dose

Cities Average Family Size Male Members Female Members Total Members

Faisalabad 7 226 266 492

Gujranwala 6 649 708 1357

Lahore 7 557 560 1117

Multan 6 154 160 314

Rawalpindi 8 566 634 1200

Total 34 2152 2328 4480

Table 188: Housing Structures of Zero Dose Children

Cities Kacha Kacha-Pacca Pacca Total

Faisalabad 21 23 23 67

Gujranwala 42 30 145 217

Lahore 100 26 41 167

Multan 2 3 42 47

Rawalpindi 59 34 56 149

Total 224 116 307 647

Table 189: Households Toilets in Zero Dose Children

Cities Connected with Street Drain

Traditional latrine/Open pit Houses without Toilets

Total

Faisalabad 7 42 18 67

Gujranwala 141 70 6 217

Lahore 42 65 60 167

Multan 41 5 1 47

Rawalpindi 61 38 50 149

Total 292 220 135 647

Table 190: Modes of Defecation in the Absence of Toilets in the Houses of Zero Dose Children

Cities Neighbor’s Toilets Public toilet Open Defecation Total

Faisalabad 0 0 18 18

Gujranwala 0 0 6 6

Lahore 0 1 59 60

Multan 0 1 0 1

Rawalpindi 0 2 48 50

Total 0 4 131 135

Background Characteristics of Fully Immunized Children

Table 191: Education level of Mothers of Fully immunized Children

Cities 0 (Illiterate) 01--05 06--10 11--15 15+ Total

Faisalabad 120 93 148 32 8 401

Gujranwala 89 137 240 106 21 593

Lahore 120 65 188 57 7 437

Multan 133 111 145 55 1 445

Rawalpindi 190 93 168 93 22 566

Total 652 499 889 343 59 2442

98

Table 192: Major Professions of Caregivers of Fully Immunized Children

Cities Job Holders Small Business Daily wage Labor Total

Faisalabad 55 95 250 400

Gujranwala 229 121 243 593

Lahore 162 112 163 437

Multan 151 132 162 445

Rawalpindi 229 105 232 566

Total 826 565 1050 2441

Table 193: Status of Financial Debt/Savings in Households of Fully Immunized Children

Cities Debt (Always / Occasional)

No Debt, No Savings Savings Total

Faisalabad 218 171 11 400

Gujranwala 314 124 155 593

Lahore 238 142 57 437

Multan 191 174 80 445

Rawalpindi 238 285 43 566

Total 1199 896 346 2441

Table 194: Family Sizes of Fully Immunized

Cities Average Family Size

Male Members Female Members Total Members

Faisalabad 9 1724 1705 3429

Gujranwala 6 1913 1908 3821

Lahore 6 1458 1339 2797

Multan 6 1378 1366 2743

Rawalpindi 7 1861 1943 3804

Total 8334 8261 16594

Table 195: Housing Structures of Fully immunized Children

Cities Kacha Kacha-Pacca Pacca Total

Faisalabad 31 149 220 400

Gujranwala 62 129 402 593

Lahore 16 61 360 437

Multan 72 43 330 445

Rawalpindi 49 125 392 566

Total 230 507 1704 2441

Table 196: Households Toilets in Fully Immunized Children

Cities Connected With Drains Traditional latrine/open pit Houses without Toilets Total

Faisalabad 90 290 20 400

Gujranwala 371 214 8 593

Lahore 339 98 0 437

Multan 332 108 5 445

Rawalpindi 337 218 11 566

Total 1469 928 44 2441

Table 197: Modes of Defecation in the Absence of Toilets in the Houses of Fully Immunized

Cities Neighbor’s Toilets Public toilet Open Defecation Total

Faisalabad 2 0 18 20

Gujranwala 0 0 8 8

Lahore 0 0 0 0

Multan 0 0 5 5

Rawalpindi 0 0 11 11

Total 2 0 42 44