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In the heart of Sindh, Pakistan, where the call for routine childhood immunisation echoed through the narrow alleys and vast landscapes, a groundbreaking initiative unfolded. The Health Department of the Government of Sindh, armed with evidence from a rigorous randomised evaluation, embarked on a mission to amplify immunisation coverage and timeliness, combating the declining trend that had gripped the region. 

As millions of children worldwide remained unvaccinated or under-vaccinated, the challenge was clear. Childhood immunisation, a proven public health hero, faced a formidable foe—declining coverage, especially in the wake of the recent pandemic. In 2021, 25 million children worldwide were left unprotected, with over 60% residing in ten countries, including Pakistan. The struggle was real, and the need for an effective, scalable solution was paramount. 

In 1978, Pakistan initiated the Expanded Program on Immunization (EPI), aiming to shield children from vaccine-preventable diseases. Yet, the persistence of diseases like polio and measles revealed gaps in reaching every child. Families, especially those in remote areas, faced a dual challenge—distance from vaccination sites and limited financial means. Despite initial enthusiasm for early vaccinations, the numbers dwindled as the immunisation schedule progressed. 

Recognising the potential of incentives to surmount financial barriers, the government collaborated with researchers to conduct a randomised evaluation. The focus: mobile conditional cash transfers (mCCTs) to caregivers. In the province of Sindh, where immunisation coverage lagged, nearly 12,000 caregiver-child pairs became participants in this crucial experiment. 

Results painted a promising picture. Small mCCTs delivered through a cost-effective platform emerged as a game-changer. The research team, led by IRD and J-PAL affiliated researchers, uncovered that these modest incentives significantly increased full immunisation coverage at 12 months and up-to-date coverage at 18 months. The amount, certainty, and format of payments played pivotal roles. Notably, airtime payments and guaranteed incentives stood out as key factors driving success. 

Armed with this evidence, the Government of Sindh stepped into action. The Choti Khushi Incentive Support Program was born in January 2022, shaped by the insights gleaned from the evaluation. A flat payment schedule of PKR 200 (US$1.26) per vaccine, delivered as mobile airtime payments, became the beacon guiding immunisation efforts. The goal is to improve coverage, timeliness, and equity. 

Funding from GiveWell, recognising the impact of incentives on immunisation, provided the necessary fuel. The mCCT program, operational in all seven high-risk districts in Sindh by the end of 2022, became a beacon of hope. Incentives flowed for routine vaccines over six visits, all tracked through the Sindh Electronic Immunization Registry (SEIR). SMS reminders, community engagement campaigns, and mass media added their voices to the cause.

The road wasn’t without obstacles. In 2022, floods briefly halted immunisation efforts, but resilient vaccinators pressed on, reaching camps and fixed sites to sustain vaccination rates. By the year’s end, 487,599 children were enrolled in the Choti Khushi Program, with 960,709 incentivised vaccines administered.

Dr. Subhash Chandir, Program Director of the IRD Maternal and Child Health Program, highlighted the transformative power of even small conditional cash transfers. These transfers, he noted, acted as social incentives, breaking down barriers and nudging caregivers toward timely and complete immunisation. The Choti Khushi program, he emphasised, was a crucial step toward achieving the Immunisation Agenda 2030, ensuring no child in Sindh was left behind.

As the scaled-up program sets its sights on reaching approximately two million children over the next two years, the journey continues. The Choti Khushi initiative stands not only as a testament to the power of evidence-based policymaking but also as a beacon of hope for the children of Sindh—a reminder that sometimes, a small incentive can make a world of difference. 

References: 

Chandir S, Siddiqi DA, Khan AJ. Mobile conditional cash transfers to improve routine childhood immunization [Internet]. The Abdul Latif Jameel Poverty Action Lab (J-PAL). [cited 2023 Dec 12]. Available from: https://www.povertyactionlab.org/case-study/mobile-conditional-cash-transfers-improve-routine-childhood-immunization?lang=pt-br 

Chandir S, Siddiqi DA, Abdullah S, Duflo E, Khan AJ, Glennerster R. Small mobile conditional cash transfers (mCCTs) of different amounts, schedules and design to improve routine childhood immunization coverage and timeliness of children aged 0-23 months in Pakistan: An open label multi-arm randomized controlled trial. EClinicalMedicine [Internet]. 2022;50(101500):101500. Available from: http://dx.doi.org/10.1016/j.eclinm.2022.101500 

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