Report of Profiles of Slums/Underserved Areas of - UNICEF

Report of Profiles of Slums/Underserved Areas of

08 Largest Cities of Pakistan

Punjab (Lahore, Rawalpindi, Multan, Gujranwala, Faisalabad)

Khyber Pakhtunkhwa (Peshawar)

Balochistan (Quetta)

Federal Capital (Islamabad)

July 2020

Acknowledgements

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 Provincial and Country office colleagues, CSOs and expanded partners for their technical support and facilitation to complete this assignment. Special acknowledgement is extended to Federal and Provincial EPI Programs, Directorate of Health Islamabad and District Department of Health in 10 largest cities of Pakistan 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 Summarys ................................................................................................................................... 1

Chapter 1: Introduction ....................................................................................................................... 3 1.1 Global Context ............................................................................................................................. 3 1.2 National Context .......................................................................................................................... 4 1.3 Provincial Context ........................................................................................................................ 5 1.4 Objectives .................................................................................................................................. 10 1.5 Rationale .................................................................................................................................... 10

Chapter 2: Methodology .................................................................................................................... 13

2 Methodology ...................................................................................................................................... 13 2.1 Study Design .............................................................................................................................. 13 2.2 Study Sites ................................................................................................................................. 13 2.3 Study Duration ........................................................................................................................... 13 2.4 Study Respondents .................................................................................................................... 14 2.5 Sampling Procedures and Sample Size .................................................................................... 14 2.6 Key Variables ............................................................................................................................. 15 2.7 Data Collection Instruments ....................................................................................................... 15 2.8 Operational Definitions ............................................................................................................... 15 2.9 Data Analysis Techniques ......................................................................................................... 17 2.10 Monitoring Mechanism ............................................................................................................... 17 2.11 Study Team & Training .............................................................................................................. 17

Chapter 3: Profile of Slums/Underserved Areas ............................................................................. 19 3.1 Slums/Underserved Areas ......................................................................................................... 19 3.2 Demography .............................................................................................................................. 21 3.3 Health Resources ...................................................................................................................... 22 3.4 Infrastructure .............................................................................................................................. 24 3.5 Social Welfare ............................................................................................................................ 27

Chapter 4: Health Resources in Union Councils ............................................................................ 31 4.1 Administrative Lay Out ............................................................................................................... 31 4.2 Health Facilities .......................................................................................................................... 32 4.3 EPI Facilities .............................................................................................................................. 33 4.4 Nutrition Services ....................................................................................................................... 34 4.5 Human Resources ..................................................................................................................... 34

Chapter 5: Status of EPI Facilities ................................................................................................... 37 5.1 Infrastructure .............................................................................................................................. 37 5.2 Systems ..................................................................................................................................... 40 5.3 Equipment and Supplies ............................................................................................................ 40 5.4 Waste Management ................................................................................................................... 41 5.5 Human Resource ....................................................................................................................... 42

Chapter 6: Situation in Super High Risk Union Councils .............................................................. 44 6.1 Health Resources of SHRUCs ................................................................................................... 44 6.2 Slums/Underserved Areas ......................................................................................................... 46 6.3 Status of Childhood Vaccination ................................................................................................ 47

Chapter 7: Conclusion and Recommendations .............................................................................. 50 7.1 Conclusion ................................................................................................................................. 50 7.2 Study Limitations ........................................................................................................................ 51 7.3 Recommendations ..................................................................................................................... 51

Annex 1: Questionnaire for Group Discussion in Slums/Underserved Areas............................... 54

Annex 2: Questionnaire for Compiling Health Resource in Union Councils ................................. 59

Annex 3: Questionnaire for EPI Facility Assessment ...................................................................... 61

Annex 4: Analysis of Profiling of Slums/Underserved Areas.......................................................... 63

Annex 5: Analysis of Health Resources of Union Councils ............................................................ 79

Annex 6: Analysis of Results of EPI Facility Assessment............................................................... 84

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Abbreviations

AIDS Acquired Immune Deficiency Syndrome

BCG Bacille Calmette Guerin

CBVs Community Based Volunteers

CHIP Civil Society Human and Institutional Development Programme

CI Confidence Interval

cMYP Country Multiyear Plan

CNIC Computerized National Identity Card

CSO Civil Society Organisation

DDMA District Disaster Management Authority

DEFF. Design Effect Factor

DPT Diphtheria, Pertussis, and Tetanus

DSV District Supervisor Vaccination

EOC Emergency Operation Centre

EPI Expanded Programme on Immunization

ESS Effective Sample Size

FSD Faisalabad

GDP Gross Domestic Product

GJR Gujranwala

IBD Islamabad

ILR Ice-Lined Refrigerator

Lead Leadership for Environment and development

LHR Lahore

LHV Lady Health Visitor

LHW Lady Health Worker

MDGs Millennium Development Goals

MICS Multiple Indicators Cluster Survey

MMR Maternal Mortality Rates

MTN Multan

NDC Natural Disaster Consortium

OPV Oral Polio Vaccine

PCV Pneumococcal Conjugate Vaccine

PDHS Pakistan Demographics and Health Survey

PKR Pakistani Rupee

PSLM Pakistan Social Living Measurement Survey

PWR Peshawar

QTA Quetta

RWP Rawalpindi

SDGs Sustainable Development Goals

SHRUCs Super High Risk Union Councils

SoP Standard Operating Procedures

SPSS Statistical Package for the Social Sciences

STATA Statistics and Data

TB Tuberculosis

TDP Temporary Displaced People

UC Union Council

UN United Nations

UN HABITAT United Nations Human Settlements Programme

UNDP United Nations Development Programme

UNHCR United Nations High Commissioner for Refugees

UNICEF United Nations Children Fund

US $ United States Dollar

WASH WCBA

Water, Sanitation and Hygiene Women of Child Bearing Age

WHO World Health Organization

WMC Waste Management Company

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Executive Summary 8 largest cities including 05 cities of Punjab, one city of Khyber Pakhtunkhwa (Peshawar), one city of Balochistan (Quetta) and Federal Capital Islamabad house 3114 slums/underserved areas. These slums/underserved areas are located in 76% of the total 626 UCs. Approximately 11.9 Million people reside in slums/underserved areas. 86% inhabitants of such areas are permanent settlers with the remaining 13% are temporarily displaced and 1% belong to other nationalities. 36% slums are found to be unregistered and hence lacked access to basic amenities such as adequate water supply and sanitation systems as well as fully functional health systems. The housing conditions in such vulnerable areas are very poor with the residents living in abysmal and dilapidated housing structures. Around 36% of the housing structures present in slums are Kacha or Kacha-Pacca (mixed). From the 99% houses having toilets, 51% have traditional/open pit toilets. On an average, 8 people use a single toilet facility. 28% slums/underserved areas do not have drains and where available 49% of them have choked/filthy drains. 75% slums/underserved areas are devoid of access to the government water supply system and hence acquire water through other sources. 25% slums/underserved areas do not have schools. Slums/underserved areas where schools are available, 44% of them are Madrassas and 74% of them are privately run set ups. 31% Union Councils (UCs) do not have Public health facility and 26% UCs do not have any EPI facility. 2% UCs do not have vaccination outreach services and 37% UCs do not have any kind of Nutrition services. 25% UCs are uncovered by Lady Health Workers (LHWs). When these variables are checked in slums/underserved areas, only 7% slums/underserved areas report access to Public/Private health and EPI facilities within 2 kilometers radius. 29% slums/underserved areas report non-provision of outreach vaccination in their respective areas. 58% slums/underserved areas are uncovered by LHWs. Two of the eight cities namely Peshawar (18) and Quetta (6) house 24 Super High Risk Union Councils (SHRUCs) for polio and routine immunization. 83% of them house 212 slums/underserved areas having 0.5 Million population residing in them. Over 90% slums/underserved areas located in SHRUCs report non-presence of health/EPI facilities. 56% of them are uncovered by LHWs. A holistic assessment of 422 EPI facilities reveal that 59% EPI facilities do not have Standard Operating Procedures (SoPs), 36% have inadequate seating capacity and 31% of such facilities do not have gender segregated waiting areas. 35% of them do not have drinking water available and 26% report unavailability of toilets. Toilets of 31% EPI facilities are gender mixed hence a cultural barrier for females for easy use. 18% report shortage of supplies, namely 2% report infrequent shortage of vaccines. 14% work for less than 6 hours a day. Findings of this report unmask a bitter truth: residents of slums/underserved areas are living in extremely vulnerable and despicable conditions. Their housing structures are dilapidated and weak and access to adequate water and sanitation facilities is meager at best. Adequate channels of waste management system are absent from such areas and low immunity levels among residents are common place with the probability of disease outbreaks being exceptionally high. Keeping in view these reprehensible conditions, it is of utmost importance that realistic micro planning of vaccinators, Community-Based Volunteers (CBVs) and LHWs is done so that adequate demand for health and EPI facilities can be generated. The holistic profiles of slums/underserved areas call for such a well-integrated delivery model so that the prevalent issues can be suitably addressed.

Box 1: Major Inequities

Health Facilities

93% slums/underserved areas have difficult access to health and EPI facilities.

58% slums/underserved areas are not covered by LHWs.

Infrastructure

59% houses of slums are Kacha (un-cemented) or Kacha-Pacca (mixed structures);

36% slums are not registered. WASH Facilities

75% slums/underserved areas do not have access to Government water supply system.

77% slums/underserved areas either do not have drains or have choked and filthy drains.

Education Facilities

25% slums/underserved areas do not have schools.

Social Welfare

51% slums/underserved areas do not have access to any kind of Public welfare schemes

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Chapter 1 Introduction

Survival is More Important than Preventive Health Care

Bilo is Aged 13 months, is not yet aware about the conditions in which he is born and would be raised into. Bilo is a resident of Rimsha colony, a slum situated in H-9 sector, Islamabad. His father, Bagha, is a daily wage worker. Bilo has two other siblings, a brother and a sister. This family of five lives in a one room tented house where the toilet is not available. The family has high debt burden. Bilo’s mother is a 23 years old illiterate woman who is unaware about the working of Lady Health Workers in her area. She is not aware of routine immunization and does not believe in preventive healthcare.

As per Bilo’s mother! “when you do not have food, you do not worry about something as lavish as preventive healthcare”.

She quotes how she has only seen the children of her neighbors being suffering from temperature after they receive a vaccination. She comments that they have almost little to no resources to spend on healthcare in case Bilo falls sick due to a vaccination. Moreover, she highlights how taking her child to a health center, which is a few kilometers away, is an ordeal for her and family. It is due to the irrational fear of Bilo’s mother and the prevailing socio-economic conditions of the household, that Bilo has not yet received even one routine vaccination.

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Chapter 1: Introduction 1.1 Global Context The World Population Growth index indicates that the current population of the world is 7.7 billion, with an annual growth rate of 1.08%1. The growth in world population has led to urbanization, where the people from rural areas are migrating towards urban areas for better economic opportunities. In 2014, over half of the population of the world (54%) was residing in the urban areas2. This proportion is expected to increase to 66% by 2050, adding an additional 2.5 billion dwellers to the urban areas, of whom around 90% will be in the urban areas of Africa and Asia3. In developing countries of these areas, the migration from rural to urban areas is mostly more-than-proportionate, leading to the development of unplanned settlements in and around cities, identified and known as “slums”. The United Nations Habitat defines “slums” as the informal settlements with high population density, poor living conditions and weak infrastructural provisions (United Nations (UN), 2016)4.

According to a study conducted on “Size distributions of slums across the globe”, around 900 million people reside in the slum areas worldwide, a number which is expected to double by 2030 (Friesen, Taubenbock & Wurm, 2019). These slums are mainly concentrated in the cities of the Global South; where the world’s largest slum regions include Khayeltisha Cape Town in South Africa; Kibera, Nairobi in Kenya; Dharavi, Mumbai in India; Orangi Town Karachi in Pakistan; Neza-Chalco-Itza and Mexico City in Mexico. As per the UN statistics of 2014, around one billion of slum dwellers are residents of the developing world (Young, 2015)5. Out of this, the percentage ratio of urban population as slum-dwellers has been lowest for Northern Africa (11.1%) and highest for Sub-Saharan Africa (55.2%), (Figure 1). South Asia stands at second highest with 30.7% of its population

living in slums as per the statistics of 2014, (UN, 2015)6. World Bank (2014) has further conducted a trend analysis on urban slum population for Brazil, China, India and Nigeria (Figure 2). The data indicates that in 1990 the percentage share of population living in slums was drastically higher for all the four countries when compared to the year 2014 (Ritchie & Roser, 2018)7. India decreased its slum population the most by 31% in the last 24 years. However, the number of slums present in India and other countries is still significant and their presence cannot be

ignored.

1 World Population Clock: 7.7 Billion People (2019) - Worldometers. (2019). Retrieved from https://www.worldometers.info/world-population/ 2 UN Habitat. World Cities Report 2016. Urbanization and Development: Emerging Futures. New York: Pub. United Nations; 2016. 3 United Nations. World Urbanization Prospects: 2014 Revision. New York: Pub. United Nations; 2014. 4 Habitat, United Nations. 2016. Housing & slum upgrading. Retrieved from http://unhabitat.org/urban-themes/housing-slum-upgrading/) 5 Young, T. (2015). 5 Largest Slums in the Pakistan [Blog]. The Borgen Project. Retrieved from https://borgenproject.org/5-largest-slums-world/ 6 United Nations. (2015). Report of the Secretary-General on the work of the Organization. Retrieved from http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2015/Statannex.pdf 7 Ritchie, H., & Roser, M. (2018). Urbanization. Retrieved 20 September 2019, from https://ourworldindata.org/urbanization#urban-slum-populations

11.120.5 24.7 25.2 27.4 30.7

55.2

NorthernAfrica

LatinAmerica &

theCaribbean

WesternAsia

EasternAsia

SouthernEast Asia

SouthernAsia

SubSaharan

Africa

Brazil, 37%

China, 44%

India, 55%

Nigeria, 77%

Brazil, 22%

China, 25% India, 24%

Nigeria, 50%

% of Slums Population 1990

Source: OWID based on World Bank, World Development Indicators –

Figure 1: Continent wise Slum Population in 2014

Figure 2: Slums Population in 1990 & 2014

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The comparison of these countries with Pakistan reveals that, Pakistan lists much lower in the number of urban slum settlements. However, when compared on the parameter of population growth between 1990 and 2014, it has been discovered that Pakistan has shown an increase in population growth for slums from nearly 16.79 million in 1990 to around 32.34 million in 2014 (Our World in Data, 2014). The conditions of slums in Pakistan in terms of population growth, health and immunization and social problems have been further investigated from the secondary data sources hereafter. 1.2 National Context 1.2.1 Population Growth The current estimated population of Pakistan is 212 Million8, making it the 5th most populous country of the world. According to the UN Population estimations, the population of Pakistan will reach to 242 Million by 20259. According to the estimation of UN for 2014, the slum population was 32 Million in urban areas of Pakistan10. Currently, 36.9% of the total population of Pakistan makes up urban population, which is expected to increase to 50.2% by 205011. The urban population is growing at the rate of 3% annually (Shaikh & Nabi, 2017). It is expected that the cities of Pakistan will accommodate 250 million people by the year 203012. The rapid urbanization can be seen in the increase of population of 8 largest cities of Pakistan in which 12.9 Million population (census 1998) has increased to 24.3 Million (census 2017). Highest population increase is noticed in Lahore where population increased from 5 Million to 11 Million. Smallest cities like Quetta and Islamabad also shows double population growth. 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 planning1314. To improve the living conditions of these settlements and to meet the Sustainable Development Goals, an improvement in the health and socioeconomic conditions of the slum-dwellers is required. However, a better understanding of the individual slum environment and the factors contributing to poor health conditions is essential to be taken into account to maintain a balance between the demand and supply of health services for the slum-dwellers. The social inequities are also to be evaluated to target the areas of improvement for slum-dwellers. 1.2.2 Status of Health Studies on the levels of immunization coverage in Pakistan reveals that the coverage has remained lower15 for urban poor, including slum residents, when compared to rural poor16. Pakistan Demographic and Health Survey (PDHS) for 2018 indicates that the 66% of children age 12-23 months have received all basic vaccinations. The coverage data is bifurcated by

8 World Bank. (2019). Population Total. Retrieved from https://data.worldbank.org/indicator/SP.POP.TOTL?locations=PK 9 United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, custom data acquired via website. 10 UNMDGs. (2019). Retrieved from mdgs.un.org 11 United Nations, Department of Economic and Social Affairs, Population Division (2018). World Urbanization Prospects: The 2018 Revision. 12 Shaikh, 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/ 13 Ibid. 14 Buque, Mindra & Duncan, T. (2016). Immunization, urbanization and slums: A review of evidence. UNICEF. 15 Ibid 16 Gotlife.gavi.org

Table 1: Population in 8 Largest Cities City Census-2017 Census-1998

Lahore 11,126,285 5,143,495

Faisalabad 3,203,846 2,008,861

Rawalpindi 2,098,231 1,409,768

Gujranwala 2,027,001 1,132,509

Peshawar 1,970,042 982,816

Multan 1,871,843 1,197,384

Islamabad 1,014,825 529,180

Quetta 1,001,205 565,137

Total 24,313,278 12,969,150

130.87 122.04

21.8640.52

16.79

187.06

100.5

41.5838.91

32.34

China India Nigeria Brazil Pakistan

Population in Millions in 2014

Population in Millions in 1990

Figure 3: Comparison of Slum Population in 1990s & 2014

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urban and rural areas, province-wise but it does not specifically highlight the disparities of the slum areas in these provinces. However, marginalization, both ethnic and economic, low awareness level including carelessness of caregivers and inaccessibility to the healthcare centers have been identified as the major reasons for low immunization coverage in the slums17. Some of the interventions like awareness programmes, community engagements, vaccination campaigns and medicine coupon incentives have yielded results in Pakistan to overcome health related issues of slums, (Crocker-Buque, Mindra, Duncan & Mounier-Jack, 2017). 1.3 Provincial Context 1.3.1 Population & Status of Health in Punjab According to Pakistan Economic Survey (2018-19), Punjab is the most populous province of Pakistan and accounts for 110 Million of population for the year 201718. The second largest city of Pakistan, and the capital of Punjab Lahore, has roughly 30% of the settlements as slums (Abubakar, 2016)19. The slums of Lahore are home to an estimated population of 1.7 million people (National Report of Pakistan for Habitat III, 2015). The proportion of slum population in Lahore has reached the upper limit threshold of the city’s total population. It has a population density of 400 persons/km (National Report of Pakistan for Habitat III, 2015). In case of the slums of Faisalabad, the number of slum-dwelling units ranges from 42 to 2,851 (Ahmed, Mustafa & Khan, 2015)20. Lahore has approximately 308 informal settlements or slums (National Report of Pakistan for Habitat III, 2015)21. Faisalabad ranks as the third most populous city of Pakistan and it is a home to 104 slums (Ahmed, Mustafa & Khan, 2015)22. A study conducted on 104 slums of Faisalabad indicates that 84% of the children are vaccinated and have received any dose of vaccine; whereas, 3.3% of the children are not vaccinated. On the other hand, 12% of the respondents are without any knowledge of vaccination22. Another study is conducted on the slums of Bahawalpur where out of the 306 children surveyed, only 26% have the vaccination cards. The highest coverage is for BCG vaccine. First dose against measles is received by as many as 84% of the children; whereas, second dose is received by only 42% of the children. 59% mothers of the children who have completed their vaccination schedule are educated over intermediate level23. 1.3.2 Population & Status of Health in Sindh Sindh is situated in the southeast of the country and is one of the four provinces of Pakistan. By area, it is the third largest province of the country and is second largest in terms of population. Sindh is the most urbanized province of Pakistan with around 52% population residing in the urban areas (Noh, 2018)24. According to 2017 Census of Pakistan, the population of the Sindh province is 47.89 million; whereas Karachi has a population of 14.9 million, which is projected to increase to 18.7 million by 2025 (Pakistan Bureau of Statistics, 2017)25. The population density for the city of Karachi is approximately 6,000 people per square kilometer. In the year 2016, UN ranked Karachi as the 12th top megacity by size in the world, the number which is expected to

17 Aleemi, A. R., Khaliqui, H., & Faisal, A. (2018). Challenges and patterns of seeking primary health care in slums of Karachi: a disaster lurking in urban shadows. Asia Pacific Journal of Public Health, 30(5), 479-490. 18 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 19 Abubakar, M. (2016). Women and slums. Retrieved 21 September 2019, from http://www.lead.org.pk/lead/postDetail.aspx?postid=326 20 Ibid. 21 National Report of Pakistan for HABITAT III. (2015). Islamabad. 22 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 23 Badar, S., Qadri, S., (2016). Childhood Immunization in Slums of Bahawalpur City. Journal of University Medical and Dental College. 7 (2). 35-40. 24 Noh, J. (2018). Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data. PLOS. 25 Sparkman, G. (2018). Challenges of slum life in Orangi Town, Karachi, Pakistan. Sparkman Center for Global Health.

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rise to 7th by 2030 (Sparkman, 2018)26. Hyderabad, on the other hand is the fourth-largest city in Pakistan with the population of 1.73 million. Hyderabad is the second most urbanized city of Sindh with around 80% of the people living in the cities27. Karachi and Hyderabad are key focus areas when it comes to unplanned urbanization and are the home to around 1,300 slums. About 70% of these slums are situated in 18 towns of Karachi, whereas, the remaining 25-30% slums are located in four towns of Hyderabad28. According to a detailed study conducted on “Challenges and patterns of seeking primary healthcare in slums of Karachi: A disaster lurking in urban shadows” it has been highlighted that there are more than 600 slums in Karachi. Karachi is also a home to the largest slum in Asia i.e. Orangi Town with the estimated population of 2.4 Million29. The MICS survey of 2014 for the Sindh province reveals that the vaccination coverage for Measles 1 in Karachi was 65.3%; whereas, it was 62.9% for Hyderabad. According to the study of Aleemi and Khalique (2018), the coverage rates are even lower for urban slums30. The study formulates that in the sample population of 400 people from 8 slums of Karachi, only 11.7% of the respondents reported the visits by Lady Health Workers (LHWs). The regular visits of LHWs in the slum communities is important because these health workers educate and promote healthy behavior and provide basic curative healthcare services. In the slum areas, where the level of education and awareness is already low, the absence of LHWs is an alarming sign, which demands immediate attention. The study further formulates that 75% of the sample population is not vaccinated for hepatitis and tetanus against 23% of the population which has received vaccination31. The reasons for no vaccination are reported to be inaccessibility, unawareness, cost and family belief system. The slums are prone to communicable diseases due to unhygienic living conditions and poor waste disposal system and therefore attention needs to be paid to improving coverage rates for routine immunization. According to the recent findings of Emergency Operation Centre (EOC) for Polio in Sindh, the vaccination coverage demands special attention in the province since 6 new cases of polio are reported in the province, out of which 3 have occurred in Karachi, whereas, two were present in Hyderabad32. Systematic approach to healthcare and vaccination coverage is required to solve the healthcare related problems of the province. 1.3.3 Population & Status of Health in Balochistan Quetta is the largest City and the Provincial Capital of Balochistan, Pakistan. The city shars its boundaries with Pishin district in the north, Ziarat in the East, Mastung in the South and Afghanistan in the West. The city is located near the Bolan Pass, which is among one of the major gateways from Central Asia to South Asia. The City is known as the “Fruit Garden of Pakistan” due to various fruit orchids in and around the city. As per the National Census of 2017, the population of Quetta City is One Million and the population of Quetta District is Two Million. Quetta is the most urbanized city of Balochistan and hosts 29% of all urban population of the province33. Though Balochistan is the largest province by area, the population of the province is the lowest at 7.7 million and is thinly dispersed around the province. The Quetta city accommodates multiple ethnic groups including Pashtuns, Baloch, Brahvi, Hazara and Punjabi and is enriched with cultural and language diversity. The multi-dimensional poverty at headcount for Quetta stands at 46% and the Average Intensity of Deprivation is 46%,

26 Sparkman, G. (2018). Challenges of slum life in Orangi Town, Karachi, Pakistan. Sparkman Center for Global Health. 27 Sparkman, G. (2018). Challenges of slum life in Orangi Town, Karachi, Pakistan. Sparkman Center for Global Health. 28 Khawar, H. (2019). A virulent strain. [online] DAWN.COM. Available at: https://www.dawn.com/news/1514595 [Accessed 15 Nov. 2019]. 29 Aleemi, A. and Khaliqui, H. (2019). Challenges and Patterns of Seeking Primary Health Care in Slums of Karachi: A Disaster Lurking in Urban Shadows. Asia Pacific Journal of Public Health, pp.1-12. 30 MICS, S. (2014). MICS Survey. [online] Mics-surveys-prod.s3.amazonaws.com. Available at: https://mics-surveys-prod.s3.amazonaws.com/MICS5/South%20Asia/Pakistan%20%28Sindh%29/2014/Final/Pakistan%20%28Sindh%29%202014%20MICS_English.pdf [Accessed 15 Nov. 2019]. 31 Aleemi, A. and Khaliqui, H. (2019). Challenges and Patterns of Seeking Primary Health Care in Slums of Karachi: A Disaster Lurking in Urban Shadows. Asia Pacific Journal of Public Health, pp.1-12. 32 Khuhro, N. (2019). Over 120,000 children in Sindh left unvaccinated per campaign: report - Daily Times. [online] Daily Times. Available at: https://dailytimes.com.pk/472464/over-120000-children-in-sindh-left-unvaccinated-per-campaign-report/ [Accessed 15 Nov. 2019]. 33 State of Pakistani Cities, 208

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thus making poverty rate in Quetta the highest among all provincial capitals of Pakistan34. Furthermore, about 17% of the population is living below poverty line in this city35. The literacy rate stands at 66% in Quetta city, however, there is a noticeable difference between literacy rates, and female literacy stands at 83%36. Major challenges of Quetta city are exponential growth-rate, lack of resources and city planning for managing a large influx of economic migrants and those affected by natural disasters or conflict. Poor access to health and Expanded Programme on Immunization (EPI) services, safe water and almost non-existent drainage system also pose serious health risks as cited by different researchers. The housing structures accommodating over 800,000 residents of Quetta lack the facilities and infrastructure for adequate drainage and sanitation37. While the situation of disposal and drainage of wastewater in the city remains poor, drainage system in the slums is almost non-existent 38. The provision of safe water is available to only 39% of the households39. Water is found to be scarce due to which a majority of residents end up paying private vendors for their water-supply40. To assess the quality of consumable water, a study was conducted in 16 different locations of Quetta, which revealed high contamination in tap water owed to the seepage and leakage of the water supply and sewer lines41. Furthermore, fecal contamination of drinking water is known to cause 30% of all diseases42. There are 47 identified slum areas as per the records of the Katchi Abadi Directorate43, although the actual numbers are higher than this. These slums are mostly accompanied by temporary houses (mud houses) with substandard basic and health facilities44. The slum areas are highly populated with poor or no infrastructure45. The slum dwellers of Quetta lack accessibility to basic resources and are living far beyond the standards laid down by the Sustainable Development Goals (SDGs). Comprehensive Multi Year Plan (cMYP) Balochistan 2014-2018 depicts acute shortage of health personnel in Quetta46. To address the health needs, there are 07 health programmes that are running in Quetta city, namely TB (Tuberculosis) Control Programme, Malaria Control Programme, Hepatitis Prevention Control Programme, AIDS (Acquired Immune Deficiency) Control Programme, National Programme on Family Planning and Primary Healthcare and National, Maternal, Newborn & Child Healthcare Programme47. Among the most common diseases reported by the health facilities are Respiratory Tract Infections, Gastrointestinal, Urinary Tract Infection and Diarrhea/ Dysentery, whereas other communicable diseases include Malaria, Meningitis, Fever and Scabies48. In terms of immunization, the Pakistan Social Living Measurement Survey (PSLM) for the year 2014-2015 reveals 65% of children aged 12-23 months in Quetta (recorded both by record ad recall) have received all basic vaccination, with the low coverage rates of 52% in rural areas and comparatively high rates of 71% in urban areas. Although 94% of the children in Quetta have received at least one vaccination, there are marked differences in the immunization status of first and third doses of DPT, Polio and Hepatitis B. About 28.5% children of age 12-23 months have

34 http://www.pk.undp.org/content/dam/pakistan/docs/MPI/MPI%204pager.pdf 35 Geography of Poverty and Public Service Delivery in Pakistan. Research Brief April 2017, Pakistan Poverty Alleviation Fund 36 http://emis.gob.pk/Uploads/QUETTA%20DISTRICT%20EDUCATION%20PLAN%20FOR%202016-2017%20TO%202020-2021.pdf 37 Urbanization Challenges in Balochistan, 2015. Pakistan Urban Forum, The Urban Unit 38 http://www.balochistan.gov.pk/index.php?option=com_content&view=article&id=839&Itemid=1087 39 Pakistan Economist 40 State of Pakistani Cities, 2018 41 Khattak M I. (2011). Study of Common Inorganic Anions in Water Samples of Quetta City By Technique Of Ion Chromatography. Sci.Int. (Lahore).23(2):135–141. 42 Aziz J A. (2005). Management of source and drinking-water quality in Pakistan. Eastern Mediterranean Health Journal. 11(5-6):1087–98 43 Qutub, S.A.; Salam, N.; Shah, K. and Anjum D. (2008). Community-based sanitation for urban poor: the case of Quetta, Pakistan 44 Growth of slum areas on rise in Balochistan Pakistan Economist, Sep 11, 2017. 45 Huma Batool.; Mega cities And Climate Change Sustainable Cities in a Changing World. LEAD Pakistan. 46 Comprehensive multi-year plan 2014-2018. Islamabad, Expanded Programme on Immunization, Balochistan 47 http://www.ndma.gov.pk/Publications/Development%20Profile%20District%20Quetta.pd 48 http://www.ndma.gov.pk/Publications/Development%20Profile%20District%20Quetta.pd

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received their first dose of BCG, while 54.2% and 13% have received doses of Polio and Hepatitis B vaccines respectively and 18% have received vaccination for measles. Balochistan Comprehensive Development Strategy (2013-2020) reveals that the health sector of the province has extremely underperformed in the last decade. The poor performance has been attributed to financial deficit of the province. The detailed evaluation of the health sector of the province indicates that the biggest challenge faced by the province is related to primary and preventive healthcare specifically in the context of mother and childcare. The study indicates that only 26% of the deliveries of the mothers in the province take place at designated health facilities, a figure 10% lower than the rest of the provinces. In the rural areas of Balochistan, over 80% deliveries by mothers take place at home and by untrained attendants increasing the risk of mother and child mortality. The sparsely populated and sparsely developed province contributes to the problems of access to health facilities. The conditions of prenatal and postnatal care delivery are also quite dismal for the province of Balochistan. Urban areas of Balochistan reveal only 55% cases of prenatal consultation, whereas, this figures drops further in the urban slums and for rural areas. The postnatal care reception is also poor for the province and only 31% of pregnant women in the province receive Tetanus Toxoid injections. Pertaining to these alarming statistics, the PDHS 2006-2007 reveals that the MMR (Mother Mortality Rate) was highest for Balochistan among four provinces at 785 maternal deaths per 100,000 births. According to the MICS report of 2010, the Infant Mortality Rate of Balochistan is also the highest among all the other provinces of the country. IMR is reported to be 89 per 1000 live births against the MDG targets of 52 per 1000 births. As per the PSLM results of 2010-2011 the overall immunization coverage rate for Balochistan is only 45% for the children under 5 years of age when compared to Punjab (86%), Khyber Pakhtunkhwa (77%) and Sindh (67%). When checked for BCG coverage of the province, the results reveal that the coverage for 12-23 months of children is only 35%, Polio 1 has been administered to 61% of the children, a figure that dipped to 46% for Polio 3 (MICS, 2010). Recently polio epidemic has reemerged in Pakistan. As per the report by Independent Monitoring Board of the Global Polio Eradication Initiative, for Balochistan, the majority of the cases for Balochistan occur in three major areas: Pishin, Killa Abdullah and Quetta. As for the status on child health, it is reported that for every 1,000 live births, 59 babies do not survive up to their first birthday and another 12 die before reaching the age of 5 years49. The prevalence of water-borne disease indicates 44% of the households are affected by Diarrhea, 25% by Gastrointestinal (GI), 21% by Cholera, 5% by Typhoid and 3% by other common diseases50. 1.3.4 Population & Status of Health in Khyber Pakhtunkhwa According to the 2017 Census of Pakistan, the population of Peshawar is 1.97 million distributed into four towns, which are further distributed into 79 Union Councils (UCs). With the highest annual growth rate of 4% in the province, the city has seen a rapid increase in population, with huge influx of Afghan refugees. According to estimates out of 80% of the Afghan refugees living in Khyber-Pakhtunkhwa, 60% resides in Peshawar valley (United Nations High Commissioner for Refugees (UNHCR) 2012). Displaced populations having low financial resources tend to settle in and around the city in squatter settlements (Katchi Abadis). Besides Afghan refugees being the main reason of slum formation in Peshawar, the floods of 2005 made 3.5 million homeless, causing destruction of more than 600,152 houses (UN-Habitat-III, 2015)51.

49 http://www.ndma.gov.pk/Publications/Development%20Profile%20District%20Quetta.pdf 50 Butt, M., & Khair, S. M. (2016). Cost of illness of water-borne diseases: a case study of Quetta. Journal of applied and emerging sciences, 5(2), pp133-143 51 National Report of Pakistan for HABITAT III. (2015). Islamabad

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A study of UN-Habitat52, identified 18 informal settlements in Peshawar city. It constitutes about 15% of the total population of Peshawar with the estimated population of 250,00053, although the actual number of people living in slums are higher than this54. As some of the studies report that slums and squatter settlements almost constitute 50-60% of the city.55 Unhygienic living condition, open defecation and lack of access to clean drinking water are a root cause of diarrheal diseases and together contribute to about 1.5 billion deaths of children below 5 years of age (UN 2007). Slums are considered to be the incubator and transmitter of infectious diseases. Tuberculosis is also reportedly prevalent in congested and densely populated slums, malaria diarrhea and respiratory infections are common among slum dwellers and children are more exposed to these diseases (Fernando 2010). With the residents living in extremely poor living conditions, the incidents of disease remain high in Peshawar. A study conducted by Urban Unit Khyber Pakhtunkhwa in the selected slums of Peshawar revealed 74% of the frequently occurring diseases are linked to unhygienic living conditions. It was also revealed that 72% of these diseases were found in children. For health services, 74% of the residents use public health facilities while 30% seek services from private health care units. A study on measles vaccination reported immunization coverage of 58% in children of age 1-2 years in Peshawar with no major gender disparity56. For better understanding of the reasons for its low prevalence, this study also revealed mother’s education as a strong factor affecting the vaccination coverage, which was found to be low for children with illiterate mothers (36%) and considerably higher (83%) for children having literate mothers. Despite all the factors, levels of immunization in slums of Pakistan have remained low57. The main cause of low levels of immunization is lack of awareness and proper policies. Lack of mother’s education regarding child’s health and diseases like measles, polio, TB, typhoid, lead to high child mortality rates58. Hence maternal knowledge is equally important in preventing children from diseases (National Disaster Consortium (NDC), 2019)59. Interventions like awareness programs, community engagements, and vaccination campaigns, medicine coupon incentives are some of the initiatives taken by Government of Pakistan to overcome health issues of slums (Crocker-Buque, Mindra, Duncan & Mounier-Jack, 2017). 1.3.5 Population & Status of Health in Islamabad Islamabad is the federal capital of Pakistan and is located within the federal Islamabad Capital Territory. According to World Population Review, the population of Islamabad is 1,095,06460. The trend analysis for population growth for the city reveals that by 2020, the city population will be almost 1.7 million and it is expected to exceed 2.2 million by the year 2030 (Review, 2019). Islamabad has also seen a proliferation in its slum development in the last two decades. About 20 years ago, there were only 12 slums in and around the city; whereas, the number is now at more than 4261. The areas in and around Sihala, Tarnol, Rawal Dam, Bani Gala, Barakahu and Golra have seen an evident surge in the population and the number of slums62. Analysis of the rapid urban development in Islamabad further reveals that the expansion of new slums, along

52 District Disaster Management Plan Peshawar. (2017). Retrieved 25 September 2019, from http://kp.gov.pk/uploads/2018/08/DDM_Plan.pdf UNHCR (2012) KP and FATA IDP Statistics (As of 01 Dec 2012). 54 DDM Plan Peshawar - Khyber Pakhtunkhwa. Accessed From: http://kp.gov.pk/uploads/2018/08/DDM_Plan.pdf 55 The walled slums : Through the looking glass into Peshawar’s belly, Accessed From: https://tribune.com.pk/story/704975/the-walled-slums-through-the-looking-glass-into-peshawars-belly/ 56 Rehman, H., Mahesar, A. L., Khalid, S. N., & Ishaq, M. (2014). Assessment of Measles Immunization in Children 1-2 Year Age in District Peshawar, Khyber Pakhtunkhwa Pakistan. In Medical Forum (Vol. 25, No. 10, pp. 50-51). 57 Haider, S. (2017). Growth of Slum Areas on the rise in Baluchistan. Pakistan Economist. 58Crocker-Buque, T., Mindra, G., Duncan, R., & Mounier-Jack, S. (2017). Immunization, urbanization and slums – a systematic review of factors and interventions. BMC Public Health, 17(1). doi: 10.1186/s12889-017-4473-7 59 Natural Disasters Consortium (NDC)., 2019. Balochistan Drought Needs Assessment 60 Review, W. (2019). World Population Review. [online] Worldpopulationreview.com. Available at: http://worldpopulationreview.com/world-cities/islamabad-population/ [Accessed 17 Oct. 2019]. 61 Qureshi, Z. (2018). Concern over proliferation of slums in Islamabad. Gulf News Asia. 62 Butt, T. (2017). Islamabad — a city with maximum slums. [online] Thenews.com.pk. Available at: https://www.thenews.com.pk/print/227624-Islamabad-a-city-with-maximum-slums [Accessed 17 Oct. 2019].

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with the old ones are appearing in the sectors like I-12 and I-14, which will further stress the already dwindling natural resources of the city. It has been estimated that more than 0.1 million people reside in more than two dozen slums situated around sectors G-7, H-9, F-6, F-7, I-11 and I-1263. Additionally, a study by (Leadership for Environment and Development (LEAD)) refers to the three slums of Islamabad named, Chora Stop Slum, Akram Gill Colony, and Mera Jaffar Slum64 with the approximate population as 5,000, 2,000 and 1,000 respectively. It is significant to note that a dozen of these slums are legally occupied by their inhabitants and are given ‘ownership’ rights by the courts65. However, everyday amenities, including clean water and sanitation, gas and electricity are unavailable to many of them. Absence of basic facilities has led to poor health conditions, social and economic disparities in these slums. According to PDHS (2017-18), all basic vaccinations are provided to 67.8% residents of Islamabad66. A study on the reasons of incomplete vaccination in children of Islamabad, sampled 803 children, of which 70.6% were completely vaccinated, 4.1% had ongoing status on vaccination, another 4.4% were partially vaccinated; whereas, 20.7% had never been vaccinated67 (zero dose). Most of the zero-dose children had uneducated parents, or those who had received education up-to primary level only. 15.4% of the parents were unaware about the need for vaccination or about the existing Expanded Programme on Immunization (EPI). 84.3% of the parents were not acquainted about the existence of vaccinators in their area. 64.7% of the parents of zero-dose children report long waiting hours, ranging between 04-05 hours, as the major reason for not vaccinating their children. 55.3% of the parents were apprehensive of the long distance to the health facility68. Around 40% of the parents of zero-dose children had trust issues when it comes to vaccination or vaccinator; whereas 38% reported the regular absence of vaccinator from their health facility69. The findings of the study indicate that an improvement is needed in the provision of vaccination facilities so that they are more accessible to the underprivileged residents of slums. Moreover, awareness about the need for vaccination in the prevailing unhygienic living conditions of slums is essential for the urban poor. 1.4 Objectives The general objective of this study was to prepare the in-depth profiling of slums and underserved areas located within the 8 largest cities located in three provinces and Islamabad, the federal capital, of Pakistan. The specific objectives of this study were to: a. To collect the socio-demographic information of the residents of slums and underserved

areas b. To assess the fixed EPI facilities located in the slums and underserved areas c. To compile the data of health and EPI recourses at the union councils level d. To determine the childhood immunization coverage rates in the slums and underserved

areas 1.5 Rationale The review of literature reveals that the data on housing infrastructures, water and sanitation practices and immunization status of children in slum areas is limited. Therefore, this study was designed and conducted for the following reasons:

63 Mohal, S. (2018). Slums continue to mushroom across Islamabad. [online] Pakistantoday.com.pk. Available at: https://www.pakistantoday.com.pk/2018/05/28/slums-continue-to-mushroom-across-islamabad/ [Accessed 17 Oct. 2019]. 64 Quadri, F., Nasrin, D., Khan, A., Bokhari, T., Tikmani, S., & Nisar, M. et al. (2013). Health Care Use Patterns for Diarrhea in Children in Low-Income Periurban Communities of Karachi, Pakistan. The American Journal of Tropical Medicine and Hygiene, 89(1_Suppl), 49-55. doi: 10.4269/ajtmh.12-0757 65 65 Mohal, S. (2018). Slums continue to mushroom across Islamabad. [online] Pakistantoday.com.pk. Available at: https://www.pakistantoday.com.pk/2018/05/28/slums-continue-to-mushroom-across-islamabad/ [Accessed 17 Oct. 2019]. 66 All basic vaccination includes; BCG, three doses of DPT-HepB-Hib (pentavalent), three doses of oral polio vaccine (excluding polio vaccine given at birth), and one dose of measles. 67 Shah, H. and Pervaiz, S. (2016). Reasons for Incomplete Vaccination in Children of Rawalpindi and Islamabad. 68 68 Shah, H. and Pervaiz, S. (2016). Reasons for Incomplete Vaccination in Children of Rawalpindi and Islamabad. 69 69 Shah, H. and Pervaiz, S. (2016). Reasons for Incomplete Vaccination in Children of Rawalpindi and Islamabad.

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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;

The cities are growing very fast and are most popular for urban migration. Systematically collected scientific data on geographical scale, locations and population of slums 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.

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Chapter 2 Methodology

Vaccination Vs Whole Day’s Wages

Nisha lives in Kachi Abadi (unorganized settlements) of Laasi Para in Bin Qasim of District Malir of Karachi City. She has 6 siblings including 3 elder brother and 3 elder sisters. Her father is a daily wage worker. Daily wage income forces family to live hand to mouth and sometime it becomes very difficult to have three times meal. The household structure is very shabby. 9 members lives in one small room using one toilet. Available public water supply lines in their locality remains dry for whole month except 2 days for few hours. To meet their daily needs, they acquire water from the small communal water tank that comes at the street corner. Nisha’s mother cannot read and write and spend most of her time at home taking care of children. She does not have any knowledge about vaccination and have not vaccinated any of her child. At the time of survey, Nisha was one and a half years old but still was not been vaccinated for any dose. With a very small age gap among 7 children, Nisha’s mother explains:

“It is very difficult to find time to go out of home. My husband takes care of responsibilities outside home. The vaccination facility is situated at the distance from our place and it cost extra time and money to go outside of the area only for vaccination. And this is not one time

activity and required many visits as well. My husband does not allow to go outside home alone and he cannot find time to take kids for vaccination by himself as it cost the loss of whole day

wage.”

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Chapter 2: Methodology

2 Methodology This chapter 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 and Provincial Expanded Programme on Immunization (EPI) Cell. 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 three key activities were conducted for the purpose of this study (Figure 4).

2.2 Study Sites

The study was conducted in the slums / underserved areas located in the city and its periphery. 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 realized 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 different intervals. The total span of the study was Nine Months.

• Slums located in 100% Union Councils of Each Largest City Line ListedProfiling of

Slums/Underserved Areas

• Public Health & EPI Facilities i& Resources in Union Councils

Compile Health & EPI Resources

• Gender Analysis of Basic Facilities

• Supplies and Vaccine

Assess Fixed EPI Facilities

Figure 4: Key activities in the study

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2.4 Study Respondents

For the purpose of this study, three key activities were conducted and each activity had different respondents.

Table 2: 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 facilities In-charge of EPI facilities B. Questionnaire for EPI Facility 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

C. Questionnaire for District or Town Health Office

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 locations, 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, 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 Volunteers (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 in each slum or underserved area. 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.

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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 than 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 Facilities The overall objectives of the assessment of fixed EPI facilities were to know the strengths and weaknesses of the service delivery system.

Step 1: Obtaining the list of fixed EPI facilities: The study team obtained the list of all fixed EPI facilities from the department of health authorities.

Step 2: Assessment of fixed EPI facilities: Once the lists were obtained, fixed EPI facilities were physically visited by the study team for assessment.

No sampling method was used for this activity. All listed fixed EPI facilities (i.e. 228) were physically visited and assessed by the study team.

Activities 3: Compile the Health & EPI Resources 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.

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 facilities 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

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.

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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. 1370).

Similarly, a slum household is defined as a group of individuals who live under the same roof that lacks one or more71 of the following conditions:

Limited access to improved water and sanitation

Weak housing structures

Insufficient living area

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.

70 UN Habitat (2010), The Challenge of Slums: Global Report on Human Settlements 2003 71 This definition may be locally adapted for where some factors may be similar between the slums and majority of the society (UN Habitat).

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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 segregated in the following categories.

Table 4: 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


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


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 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 & Training A three-tiered teams were engaged in in-depth profiling of slums and underserved areas, assessment of fixed EPI facilities in slums and underserved areas and compilation of health and EPI resources data of union councils.

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).

1. Team Leader Supervisors

Data Collectors

Data Entry Operators

2. Data Validation Team

Data Assistant

3. Report Writer Data Analyst

Graphic Designer

Figure 5: Study team composition

18

Chapter 3 Profile of Slums/Underserved Areas

11.9 Million

People live in Slums/

Underserved Areas

93% Slums/ Underserved

Areas Report No

Access to EPI

Facilities


Areas

Report No Access to

Public Health Facilities


Areas are not covered

by LHWs


Areas Report No

Coverage for

Outreach

19

Chapter 3: Profile of Slums/Underserved Areas

Slums/Underserved areas form a major portion of the largest cities’ population. Consolidated information about names, addresses and population sizes of these areas are unavailable for realistic planning and extension of 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 locations, their holistic profiles are being prepared. This chapter presents the profile of slums/underserved areas of 8 largest cities located in three provinces and Islamabad, the federal capital, of Pakistan. The profiles are presented around the following five broader categories: 3.1 Slums/Underserved Areas 3.1.1 Union Councils with/without Slums/Underserved Areas 3.1.2 Number of Slums/Underserved Areas 3.1.3 Timelines of Existence 3.1.4 Legal Status 3.2 Demography 3.2.1 Population 3.2.2 Types of Residents 3.3 Health Resources 3.3.1 Health Facilities 3.3.2 EPI Facilities 3.3.3 Outreach Vaccination 3.3.4 Health Workers 3.3.5 Emergency Health Services 3.4 Infrastructure 3.4.1 Housing Structures 3.4.2 Household Toilets 3.4.3 Domestic Water 3.4.4 Waste Management 3.5 Social Welfare 3.5.1 Schools 3.5.2 Civil Society Organizations 3.5.3 Informal Groups 3.5.4 Social Welfare Schemes

3.1 Slums/Underserved Areas

3.1.1 Union Councils with/without Slums/Underserved The 08 cities are sub-divided into 31 towns, which are further divided into 626 UCs. 76% Union Councils house 3114 slums/underserved areas. These 76% UCs house a greater number of slums (1779) compared to underserved areas (1335). Highest percentage of spread of slums/underserved areas across UCs is found in Gujranwala (91%). The lowest spread of slums/underserved areas across UCs is found in Quetta (44%). Around 70% UCs house slums/underserved areas in remaining cities.

44%

73%

76%

77%

77%

77%

88%

91%

76%

QTA

RWP

FSD

IBD

MTN

LHR

PWR

GJR

Total

Figure 6: % UCs with Slums/Underserved

20

3.1.2 Slums/Underserved Areas Overall, there are 1779 slums and 1335 underserved areas located in 478 UCs. The highest number of slums is found in Peshawar (550) followed by Lahore (356) and Quetta (281). While the number of underserved areas is highest in Lahore (637) and Faisalabad (297). The lowest number of slums/underserved areas is found in Islamabad. The greater number of slums/underserved does not refer to greater number of population size. The sizes of slums vary across each city hence these numbers need to be analysed according to their population sizes (Annex 4 Table 4).

3.1.3 Timelines of Existence Overall, the emergence of slums has been lowest before 1950s (24%) and after 1991 (18%). The growth of slums is highest during 1950 to 1990 (58%) at a similar pace for all 08 cities. The lowest growth during 1950s to 1990s is found in Peshawar (48%). The highest growth of slums before 1990s is found in Islamabad (72%) and Faisalabad (65%). The growth of slums during 1950s to 1990s could be because of industrial growth or decline of agricultural profits. The lowest growth of slums after 1991 is seen in Peshawar where percentage of slum growth drops from 48% to only 9%. 3.1.4 Legal Status 36% slums are not registered72 with highest unregistered slums in Quetta (57%), Islamabad (57%) and Peshawar (50%). In Punjab, the percentage varies across cities, as Gujranwala (43%) has the highest percentage of unregistered slums. whereas, they are lowest for Faisalabad (11%), Multan (17%) and Lahore (18%). The registration status of slums determines 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.

72 Registration status is reported against address mentioned on electricity bill and CNIC

Table 5: Number of Slums/Underserved

Cities Slums Underserved Total

Faisalabad 169 297 466

Gujranwala 82 165 247

Lahore 356 637 993

Multan 216 104 320

Rawalpindi 76 62 138

Islamabad 49 14 63

Quetta 281 34 315

Peshawar 550 22 572

Total 1779 1335 3114

21%

15%

20%

21%

10%

0%

9%

43%

24%

59%

60%

61%

63%

65%

72%

62%

48%

58%

20%

25%

19%

16%

25%

28%

29%

9%

18%

GJR

MTN

RWP

LHR

FSD

IBD

QTA

PWR

Total

1991 onwards 1951-1990 Before 1950

11%17% 18%

24%

43%

50%

57% 57%

36%

FSD MTN LHR RWP GJR PWR IBD QTA Total

Figure 7: Timelines of Existence of Slums

Figure 8: % of Unregistered Slums

21

3.2 Demography 3.2.1 Population There are approximately 11.9 Million people living in slums/underserved areas, which is about 49% of the total population (24.3 Million)73 of the 8 cities surveyed. The higher population share resides in underserved areas as compared to slums. The largest population size in slums/underserved areas is found in Lahore (4.6 Million) followed by slums/underserved areas of Peshawar (1.5 Million). The lowest population size is found in slums/underserved areas of Islamabad (0.37 Million). Overall, approximate population of children aged 0-11 months74 residing in slums/underserved areas is 0.38 Million. City wise comparison reflects highest number of target population resides in Lahore followed by Peshawar. Lowest number of target population resides in Islamabad, Quetta and Multan. The population of children under 5 75 years of age residing in slums/underserved area is 2 Million. With the similar trends, the highest number of children under 5 years of age is found in Lahore followed by Peshawar. The lowest number of children under 5 years of age is found in Islamabad. The approximate population of child bearing age women76 residing in slums/underserved areas of 8 largest cities of Pakistan is 2.6 Million. Slums/Underserved areas of Lahore stand first with the highest concentration of population of child bearing age women. Slums/Underserved areas of Islamabad share merely 3% of the total population residing in slums/underserved areas.

73 National census 2017 74 3.5% and 92% survival of total population 75 17% of total population 76 22% of total population

Table 6: Approximate Population of Slums/Underserved


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

Islamabad 273,840 105,800 379,640

Quetta 633,508 78,896 712,404

Peshawar 1,480,942 51,536 1,532,478

Total 5,680,568 6,294,653 11,975,221

Table 7: Approximate Population of Children 0-11 Months


Faisalabad 14,790 28,370 43,160

Gujranwala 9,325 37,994 47,319

Lahore 48, 942 100,796 149,738

Multan 15,818 13,919 29,737

Rawalpindi 17,135 14,002 31,137

Islamabad 8,818 3,407 12,224

Quetta 20,399 2,540 22,939

Peshawar 47,686 1,659 49,346

Total 182,913 202,687 385,600

Table 8: Approximate Population Children Under 5 Years of Age


Faisalabad 78,086 149,778 227,864

Gujranwala 49,234 200,589 249,823

Lahore 258,389 532,154 790,543

Multan 83,513 73,486 156,999

Rawalpindi 90,466 73,923 164,389

Islamabad 46,553 17,986 64,539

Quetta 107,696 13,412 121,108

Peshawar 251,760 8,761 260,521

Total 965,697 1,070,089 2,035,786

Table 9: Population of Child Bearing Age Women


Faisalabad 101,052 193,831 294,883

Gujranwala 63,714 259,587 323,301

Lahore 334,386 688,670 1,023,056

Multan 108,075 950,99 203,174

Rawalpindi 117,074 956,66 212,740

Islamabad 60,245 23,276 83,521

Quetta 139,372 17,357 156,729

Peshawar 325,807 11,338 337,145

Total 1,249,725 1,384,824 2,634,549

22

3.2.2 Types of Residents 3.2.2a Permanent Settlers Overall 86% residents of slums/underserved areas are living in these locations for more than two years hence are called permanent settlers. Highest proportion of permanent settlers is found in slums/underserved areas of Gujranwala (92%) and Islamabad (90%). Lowest proportion of permanent settlers is found in Quetta (76%). Over 80% of residents of slums/underserved areas are permanent in all other cities. 3.2.2.b Temporary Displaced Overall 13% residents of slums/underserved areas are temporarily displaced. Highest proportion of temporary displaced is found in Peshawar (19%), Rawalpindi (19%) and Faisalabad (18%). Lowest proportion of temporary displaced is found in Islamabad (3%), Quetta (7%) and Gujranwala (8%). Over 10% residents are found temporary displaced in Lahore (11%) and Multan (11%). 3.2.2c Other Nationalities Overall 1% residents of slums/underserved areas belong to other Nationalities. Residents belonging to other Nationalities are found in five out of eight cities. Highest concentration of residents belonging to other Nationalities are found in Islamabad (10%) followed by Peshawar (6%) and Quetta (5%). A negligible percentage of residents belonging to other Nationalities are found in slums/underserved areas of Multan (1%) and Rawalpindi (2%). 3.3 Health Resources 3.3.1 Health Facilities 31% UCs do not have Public health Facilities. Intra-city comparison within Punjab reveals the highest percentage of UCs lacking public health facilities being driven mainly from Gujranwala where 70% UCs do not house such facilities followed by Faisalabad (54%) and Rawalpindi (53%). A large percentage of UCs in Islamabad (35%) followed by Quetta (20%) and Peshawar (18%) are also without public health facilities. It is interesting to note that only 2% slums/underserved areas report their access to Public/Private health facilities within 2 kilometers, radius.

Table 10: Permanent Settlers

Cities Slum Underserved Total

Faisalabad 81% 83% 82%

Gujranwala 96% 91% 92%

Lahore 87% 89% 89%

Multan 87% 91% 89%

Rawalpindi 76% 81% 78%

Islamabad 88% 95% 90%

Quetta 88% 76% 87%

Peshawar 75% 89% 75%

Total 83% 88% 86%

Table 11: Temporary Displaced Cities Slum Underserved Total


Gujranwala 4% 9% 8%

Lahore 13% 10% 11%

Multan 12% 9% 11%


Islamabad 2% 5% 3%

Quetta 7% 8% 7%


Total 14% 12% 13%

Table 12: Residents Belonging to Other Nationalities

Cities Slum Underserved Total

Faisalabad 0% 0% 0%

Gujranwala 0% 0% 0%

Lahore 0% 0% 0%

Multan 1% 1% 1%

Rawalpindi 3% 0% 2%

Islamabad 10% 0% 8%

Quetta 5% 16% 6%

Peshawar 6% 0% 6%

Total 3% 0% 1%

Table 13: UCs with/without Health Facilities Cities

UCs with Health Facilities

UCs without Health Facilities Total



Lahore 96% 4% 100%

Multan 68% 32% 100%



Quetta 80% 20% 100%

Peshawar 82% 18% 100%

Total 69% 31% 100%

23

3.3.2 EPI Facilities Overall, 26% Union Councils do not have any EPI facilities. The percentage of UCs without EPI facilities is highest in Gujranwala (72%) followed by Rawalpindi (52%), Faisalabad (45%) and Multan (32%). 99% UCs of Lahore have EPI facilities. It is interesting to note that only 7% slums/underserved areas report about the presence of EPI facility within 2 km radius. The highest percentage of slums/underserved areas that mention about the presence of EPI facility with an easy access is in Lahore (8%) and Peshawar (8%). 3.3.3 Outreach Vaccination 71% slums/underserved areas report provision of outreach vaccination services in their areas. When non-provision of outreach vaccination service is analyzed, the highest percentage of slums/underserved areas of Gujranwala (69%), Quetta (64%) and Faisalabad (36%) stands out. Whereas this percentage is comparatively lowest in slums/underserved areas of Peshawar (4%), Multan (5%) and Rawalpindi (7%). 3.3.4 Health Workers 3.3.4a Lady Health Workers Overall, LHWs are not found in 58% slums/underserved areas.77 More underserved areas are uncovered by LHWs (62%) as compared to slums (55%). Majority of the slums/underserved of Gujranwala (85%) and Faisalabad (78%) report that their areas are uncovered by LHWs. The percentage of slums/underserved areas uncovered for LHWs is low in Peshawar (41%) and Lahore (45%). 3.3.4b Dengue Workers Overall 36% slums/underserved areas do not have dengue workers present in them. 83% slums/underserved areas of Peshawar are without dengue workers; while in Faisalabad (55%), Islamabad78 54% and Gujranwala (45%) slums/underserved areas do not have dengue workers in them. Although all slums/ underserved areas of Rawalpindi have dengue workers available but a small percentage of slums/underserved areas of Lahore (20%) and Multan (13%) do not have dengue workers.

77 The percentage total is calculated by dividing the number of slums and underserved areas with LHWs to the total number of slums and underserved areas per city. 78 In Islamabad Capital Development Authority (CDA) deploy staff on temporary basis only during dengue season. .

Table 13: UCs with/without EPI Facilities

Cities UCs with EPI Facilities

UCs without EPI Facilities Total



Lahore 99% 1% 100%

Multan 68% 32% 100%



Quetta 82% 18% 100%


Total 74% 26% 100%

Table 14: Availability of Outreach Vaccination Cities Slums Underserved Total



Lahore 83% 67% 73%

Multan 93% 100% 95%



Quetta 36% 35% 36%

Peshawar 96% 100% 96%

Total 77% 65% 71%

Table 15: LHWs Uncovered Slums/Underserved Areas Cities Slums Underserved Total



Lahore 38% 49% 45%

Multan 68% 63% 66%



Quetta 67% 68% 67%


Total 55% 62% 58%

Table 16: Unavailability of Dengue Workers Cities Slums Underserved Total



Lahore 24% 17% 20%

Multan 17% 7% 13%

Rawalpindi 0% 0% 0%


Quetta NA NA NA


Total 46% 31% 36%

24

3.3.5 Emergency Health Services On the whole, 14% slums/underserved areas are unaware of 1122 services. High percentage (35%) of residents of slums/underserved areas of Islamabad is unaware of 1122 service. Within the 5 cities of Punjab, a very negligible percentage of slums/underserved areas of Multan (1%), Faisalabad (6%) and Gujranwala (6%) report unawareness about 1122 services. 100% slums/underserved areas of Rawalpindi report about the awareness of 1122 services.79 As compared to 1122 emergency services, a stark contrast can be observed with respect to unawareness of 1038 services where in nearly all cities surveyed, the percentages are close to, if not in actuality, a full 100%. Overall (97%) slums/underserved areas are unaware of 1038 service. No slum or underserved area in Rawalpindi and Multan are aware of 1038 services. A negligible percentage of slums/underserved areas report their awareness of 1038 service in Gujranwala (1%), Faisalabad (3%) and Lahore (5%). Only 14% slums/underserved areas of Islamabad report about the awareness of 1038 services.

3.4 Infrastructure

3.4.1 Housing Structures 3.4.1a Kacha Overall 20% houses in slums are found with Kacha/tented structures while none of the housing structures in underserved areas are found with Kacha/tented structures. Highest percentage of Kacha/tented structures is found in Quetta (66%), followed by Peshawar (23%) while the lowest proportion of Kacha/tented structures are found in Faisalabad (9%) and Multan (9%). 3.4.1b Kacha-Pacca Overall 26% housing structures in slums/underserved areas are found Kacha Pacca. Greater percentage of slums (39%) has Kacha-Pacca housing structures compared to underserved areas (14%). Highest percentage of Kacha Pacca structures is found in slums/underserved areas of Multan (33%), Faisalabad (30%), Rawalpindi (30%) and Peshawar (30%).

79 1122 service do not exist in Quetta City

Table 17: Unawareness about 1122 Service Cities Slums Underserved Total

Faisalabad 8% 4% 6%

Gujranwala 0% 9% 6%

Lahore 28% 8% 15%

Multan 1% 1% 1%

Rawalpindi 0% 0% 0%


Quetta NA NA NA


Total 20% 7% 14%

Table 18: Unawareness about 1038 Services Cities Slums Underserved Total



Lahore 97% 94% 95%

Multan 100% 100% 100%



Quetta NA NA NA

Peshawar NA NA NA

Total 98% 96% 97%

Table 19: Kacha/Tented Housing Structures Cities Slums Underserved Total

Faisalabad 9% 0% 3%


Lahore 13% 0% 5%

Multan 9% 0% 5%



Quetta 66% 0% 60%

Peshawar 23% 0% 22%

Total 20% 0% 10%

Table 20: Kacha-Pacca Housing Structures Cities Slums Underserved Total



Lahore 52% 5% 22%

Multan 42% 21% 33%



Quetta 22% 7% 21%


Total 39% 14% 26%

25

3.4.1c Pacca Overall 64% houses in slums/underserved areas are found with Pacca structures. Greater percentage of housing structures of underserved areas is Pacca (86%) compared to slums (41%). The lowest percentage of Pacca housing structures is found in slums of Quetta (12%). Over 70% housing structures of underserved areas of all cities have Pacca housing structures except Islamabad (41%). The highest percentage of Pacca housing structures is found in underserved areas of Lahore (95%) and Quetta (93%). 3.4.2 Household Toilets 3.4.2a Housing Structures without Toilets Overall 1% housing structures in slums/underserved areas are found without toilets. Greater percentage of housing structures in slums (2%) is found without toilets compared to underserved areas (1%). Highest percentage of housing structures in Quetta (5%) is found without toilets across eight cities. None of the housing structures are without toilets in underserved areas of four cities. The only exception is Quetta where 6% housing structures of underserved areas are found without toilets. 3.4.2b Types of Toilets Overall 51% housing structures have open pit/traditional toilets. Housing structures of almost an equal percentage of slums/ underserved areas have open pit/traditional toilets. Highest percentage of open pit/traditional toilets is found in Quetta (87%) followed by Peshawar (62%). Over 50% toilets in slums/underserved areas of six cities are open pit/traditional.

About half of the available toilets in slums/underserved areas are connected with the street drains. Highest percentage of toilets connected with street drains are found in slums/underserved areas of Gujranwala (68%) and Faisalabad (61%). Lowest percentage of toilets connected with street drains are found in Quetta (13%). Less than 50% toilets connected with street drains are found in Peshawar (38%), Rawalpindi (41%), Multan (47%) and Lahore (49%). On an average, 8 persons use single toilet facility. Highest number of average users of single toilet is found in Quetta (9) and Peshawar (9). In the absence of toilet facility, residents of slums/underserved areas practice open defecation. 11% slums report open defecation and 3% underserved areas. The practice of open defecation is highest in slums/underserved areas of Islamabad (21%) and Peshawar (12%) (Table 21c Annex 5).

Table 21: Pacca Housing Structures Cities Slums Underserved Total



Lahore 35% 95% 74%

Multan 49% 79% 61%



Quetta 12% 93% 19%


Total 41% 86% 64%

Table 22: Housing Structures without Toilets Cities Slums Underserved Total

Faisalabad 2% 1% 1%

Gujranwala 1% 0% 1%

Lahore 2% 0% 1%

Multan 1% 6% 3%

Rawalpindi 1% 0% 0%

Islamabad 3% 0% 2%

Quetta 5% 6% 5%

Peshawar 2% 1% 2%

Total 2% 1% 1%

Table 23: Open Pit/Traditional Toilets Cities Slums Underserved Total



Lahore 37% 58% 51%

Multan 48% 60% 53%



Quetta 88% 79% 87%


Total 52% 50% 51%

Table 24: Toilet with Connected Street Drains Cities Slums Underserved Total



Lahore 63% 42% 49%

Multan 52% 40% 47%



Quetta 12% 21% 13%


Total 48% 50% 49%

26

3.4.3 Domestic Water Overall, only 25% slums/underserved areas have access to government water supply for domestic use. Highest percentage of slums/underserved areas of Rawalpindi (41%) and Lahore (39%) has access to government water supply. A very low percentage of slums/underserved areas of Peshawar (12%) and Gujranwala (12%) have access to government water supply. Overall almost half of the slums/underserved areas use ground water for domestic purposes. When slums/underserved areas are compared for the use of ground water, it is found that majority of slums (60%) use ground water compared to underserved areas (34%). Highest percentage of users of ground water is found in slums/underserved areas of Peshawar (87%) and Multan (64%). Lowest percentage of users of ground water is found in slums/underserved areas of Quetta (26%). Overall about a quarter of slums/underserved areas use other sources80 of water for domestic purposes. Higher percentage of underserved areas (31%) relies on other sources of water compared to slums (22%). Highest percentage of underserved areas in Faisalabad (55%) and Quetta (53%) rely on other sources of water for domestic purposes. 3.4.4 Waste Management 3.4.4a For Liquid Waste Overall, 28% slums/underserved areas do not have drains. Highest percentage of slums/underserved areas in Lahore (46%) followed by Quetta (37%), Islamabad (35%) and Gujranwala (32%) are found without drains. Lowest percentage of slums/underserved areas in Peshawar (4%) report about absence of drains in them. More than half of the slums/underserved areas have choked/filthy drains. Highest percentage of slums/underserved area in Peshawar (63%) followed by Faisalabad (56%), Multan (52%) and Gujranwala (52%) has choked/filthy drains. Similarly a substantial percentage of slums/underserved areas in Quetta (47%), Islamabad (40%) and Lahore (38%) have choked/filthy drains.

80 Other sources of water include water tanks, Masjid, neighboring areas etc.

Table 25: Access to Government Water Supply Cities Slums Underserved Total



Lahore 32% 43% 39%

Multan 18% 27% 21%



Quetta 12% 35% 15%

Peshawar 12% 9% 12%

Total 18% 35% 25%

Table 26: Ground Water Cities Slums Underserved Total



Lahore 33% 41% 38%

Multan 73% 45% 64%



Quetta 27% 12% 26%


Total 60% 34% 49%

Table 27: Acquire from Other Sources Cities Slums Underserved Total



Lahore 35% 16% 22%

Multan 8% 29% 15%



Quetta 61% 53% 59%

Peshawar 1% 0% 1%

Total 22% 31% 25%

Table 28: No Drains Cities Slums Underserved Total



Lahore 34% 52% 46%

Multan 18% 36% 24%



Quetta 40% 15% 37%

Peshawar 4% 5% 4%

Total 22% 36% 28%

Table 29: Choked/Filthy Drains Cities Slums Underserved Total



Lahore 40% 38% 38%

Multan 56% 43% 52%



Quetta 47% 53% 47%


Total 51% 46% 49%

27

Overall 23% slums/underserved areas have drains with running water. Highest percentage of slums/underserved areas of Rawalpindi (49%) followed by Peshawar (32%) is found drains with running water. Very small percentage of drains of slums/underserved areas of three cities namely Gujranwala (16%), Lahore (16%) and Quetta (16%) are found drains with running water. 3.4.4b For Solid Waste Overall 55% slums/underserved areas do not have waste pick up facility provided by the government hence majority of them throw their waste on empty plots or in streets. Higher percentage of slums (66%) compared to underserved areas (41%) throw waste on empty plots or in streets. City wise comparison found that the highest percentage of slums/underserved areas in Quetta (91%), Gujranwala (75%) and Islamabad (72%) throw waste on empty plots or in streets. Lowest percentage of slums/underserved areas in Lahore throws their waste on empty plots or in streets. Overall 40% slums/underserved areas have solid waste pick up facility by the government. Higher percentage of underserved areas (55%) compared to slums (30%) have waste pick up facility by the government. City wise comparison found that the highest percentage of slums/underserved areas in Lahore (63%), Rawalpindi (49%) and Multan (42%) has waste pick up facility by the government. Lowest percentage of slums/underserved areas in Quetta (7%), Gujranwala (18%) and Islamabad have waste pick up facility by government. Overall 4% slums/underserved areas have self-system for solid waste management. Most of the self-system includes burning and or burying of the waste. City wise comparison reflects that 10% slums/underserved areas of Peshawar followed by Gujranwala (7%) and Faisalabad (4%) practice self system. Lowest percentage of slums/underserved areas with self-system is found in Rawalpindi (1%) and Multan (1%). 3.5 Social Welfare

3.5.1 Schools Overall, 25% slums/underserved areas are without schools. Highest percentage of absences of schools is found in slums/underserved areas of Quetta (47%). Lowest percentage of absence of schools is found in slums/underserved areas are Lahore (20%), Multan (19%) and Peshawar (16%).

Table 30: Drains have Running Water




Lahore 26% 10% 16%

Multan 25% 21% 24%



Quetta 14% 32% 16%


Total 26% 18% 23%

Table 31: Throw Solid Waste on Empty Plots/Streets Cities Slums Underserved Total



Lahore 52% 26% 35%

Multan 62% 46% 57%



Quetta 93% 76% 91%


Total 66% 41% 55%

Table 32: WMC Vehicle Picks Up Solid Waste Cities Slums Underserved Total



Lahore 47% 72% 63%

Multan 37% 53% 42%



Quetta 5% 24% 7%


Total 30% 55% 40%

Table 33: Self System for Solid Waste Management Cities Slums Underserved Total

Faisalabad 4% 5% 4%

Gujranwala 5% 8% 7%

Lahore 1% 2% 2%

Multan 1% 1% 1%

Rawalpindi 0% 3% 1%

Islamabad 2% 7% 3%

Quetta 2% 0% 2%


Total 4% 4% 4%

Table 34: Slums/Underserved without Schools Cities Slums Underserved Total



Lahore 22% 19% 20%

Multan 20% 17% 19%



Quetta 48% 32% 47%

Peshawar 17% 0% 16%

Total 27% 23% 25%

28

Overall, 64% slums/underserved areas have government schools. Higher percentage of government schools is found in slums/underserved of Quetta (78%), Multan (78%), Peshawar (74%) and Islamabad (70%). About half of the slums/ underserved areas of Gujranwala (55%) and Faisalabad (51%) report presence of Government schools. A higher percentage of slums (69%) have presence of Government schools compare to underserved areas (58%). Highest percentage of Government schools is found in slums of Multan (81%), Peshawar (73%) and Islamabad (73%). Lowest presence of government schools found in Faisalabad (52%) and Gujranwala (56%). Similarly highest percentage of Government schools is found in underserved areas of Quetta (96%), Peshawar (91%) and Multan (71%). Lowest presence of government schools found in Faisalabad (51%), Gujranwala (54%) and Lahore (57%). A significantly higher percentage of schools are run by Madrassa (44%) and Private agencies (74%) in slums/underserved areas (Table 25 c Annex 4). 3.5.2 Civil Society Organizations (CSOs) Overall CSOs are working in 3% slums/ underserved areas. City wise comparison reflects that slums/underserved areas of Quetta and Multan have no presence of CSOs. CSOs are found in highest percentage of slums/underserved areas of Islamabad (31%). A negligible percentage of slums/underserved areas of Lahore (4%), Rawalpindi (3%), Faisalabad (3%), Peshawar (1%) and Gujranwala (1%) also report about working of CSOs. Slums/underserved areas where CSOs are found, majority of them are working either on education and or health (Table 28c Annex 4). Slums of Quetta, Multan and Gujranwala do not report presence of any CSO within them. CSOs are found in highest percentage of slums of Islamabad (29%). A negligible percentage of slums of Lahore (3%), Rawalpindi (4%), Faisalabad (1%) and Peshawar (1%) also report about working of CSOs. Underserved areas of Quetta and Peshawar have no presence of CSOs. Less than 10% underserved areas of Islamabad (7%), Faisalabad (4%) and Lahore (4%) report about working of CSOs within them. A negligible percentage of underserved areas of Rawalpindi (2%), Multan (1%) and Gujranwala (1%) also report about working of CSOs within them. 3.5.3 Informal Groups Overall 35% slums/underserved areas have informal groups. Highest percentage of informal groups is found in slums/underserved areas of Rawalpindi (59%) and Islamabad (46%) while lowest percentage of informal groups is found in slums of Quetta (14%). The percentage of presence of informal groups is higher in underserved areas (39%) compared to slums (32%) Highest percentage of informal groups is found in slums of Rawalpindi (57%) and Islamabad (51%). The lowest presence of informal groups is found in slums of Quetta (15%).

Table 35: Presence of Government Schools Cities Slums Underserved Total



Lahore 68% 57% 60%

Multan 81% 71% 78%



Quetta 75% 96% 78%


Total 69% 58% 64%

Table 36: Presence of CSOs Cities Slums Underserved Total

Faisalabad 1% 4% 3%

Gujranwala 0% 1% 1%

Lahore 3% 4% 4%

Multan 0% 1% 0%

Rawalpindi 4% 2% 3%


Quetta 0% 0% 0%

Peshawar 1% 0% 1%

Total 2% 3% 3%

Table 37: Informal Groups Cities Slums Underserved Total



Lahore 39% 43% 42%

Multan 40% 32% 37%



Quetta 15% 6% 14%


Total 32% 39% 35%

29

Highest percentage of informal groups is found in underserved areas of Rawalpindi (63%), Peshawar (45%) and Lahore (43%). Lowest percentage of informal groups is found in underserved areas of Quetta (6%).

3.5.4 Public Welfare Schemes Overall 49% slums/underserved areas have public welfare schemes. The highest percentage of public welfare schemes is found in slums/underserved areas of Lahore (66%), Gujranwala (55%) and Peshawar (54%). The lowest percentage of public welfare schemes is found in Quetta (11%). Highest percentage of public welfare schemes is found in slums of Peshawar (54%), Islamabad (43%) and Gujranwala (49%). The lowest availability is found in slums of Quetta (12%). The majority of Public welfare schemes include loan schemes, stipend schemes, social benefit card and vocational skills schemes. (Table 32 Annex 4). The percentage of public welfare schemes in underserved areas is higher (61%) than slums (40%). The highest percentage of public welfare schemes is found in underserved area of Lahore (80%), Gujranwala (59%) and Faisalabad (46%). The lowest availability of public welfare schemes is found in underserved areas of Multan (27%) and Islamabad (29%). No public welfare schemes are found in underserved areas of Quetta.

Table 38: Availability of Public Welfare Schemes Cities Slums Underserved Total



Lahore 41% 80% 66%

Multan 37% 27% 34%



Quetta 12% 0% 11%


Total 40% 61% 49%

30

Chapter 4 Health Resources in Union Councils

76% 478 UCs have

either Slum or

Underserved Areas

26% 165 UCs are Without

EPI Facilities


Public Health

Facilities


Nutrition Services

25% 159 UCs are not

Covered by Lady

Health Workers

31

Chapter 4: Health Resources in Union Councils

Administratively, Pakistan is sub divided into four provinces and federally administered areas including Islamabad, Azad Kashmir and Gilgit Baltistan. These provinces are sub-divided into districts, which are further divided into tehsils/towns. The latter are split into smaller administrative structures called UCs. Depending on the context and rural/urban settings of each province, each UC has approximately 5-15 villages/areas located within them. Headed by the UC Secretary, each UC has a UC office and has at his disposal, certain resources for the development of villages/areas of that particular UC. These resources are directly correlated to the performance output of that particular UC. This chapter is focused on the status of health resources of 626 UCs of eight cities of three provinces namely Punjab (Lahore, Gujranwala, Multan, Faisalabad and Rawalpindi), Khyber Pakhtunkhwa (Peshawar), Balochistan (Quetta) and Islamabad. For each city, the data has been collected from the District Health Department with heavy reliance on the data provided by District EPI Coordinator/ DOH Preventive and District Supervisor Vaccination (DSV). The prevalent situation of health resources at the level of UC is split into the following sub-topics: 4.1 Administrative Lay Out 4.1.1 UCs with/without

Slums/Underserved Areas 4.2 Health Facilities 4.2.1 UCs with/without Health

Facilities, 4.2.2 Number of health Facilities

Vs. UCs 4.3 EPI Facilities 4.3.1 UCs with/without EPI

Facilities 4.3.2 Number of EPI Facilities

Vs. UCs 4.3.3 Outreach Vaccination 4.3.4 Cold Chain 4.4 Nutrition Services 4.4.1 Presence of Nutrition Services 4.4.2 Types of Nutrition Services 4.5 Human Resources 4.5.1 Vaccinators Per EPI Facilities 4.5.2 Lady Health Workers 4.5.3 Dengue Workers

4.1 Administrative Lay Out

The eight largest cities are administratively distributed into 31 towns and 626 UCs. 76% of 626 UCs house slums/underserved areas. Highest spread of slums/underserved areas across UCs is found in Gujranwala (91%) and lowest spread of slums/underserved areas across UCs is found in Quetta (44%). More than 70% of UCs of seven cities house slums/underserved areas.

Table 39: UCs with/without Slums/Underserved

Cities Towns Total UCs UCs With Slums & Underserved

Faisalabad 4 113 86 76%

Gujranwala 4 64 58 91%

Lahore 10 166 127 77%

Multan 4 50 36 72%

Rawalpindi 3 60 44 73%

Islamabad NA 26 20 77%

Quetta 2 50 22 44%

Peshawar 4 97 85 88%

Total 31 626 478 76%

32

Although, the spread of slums/ underserved areas are higher in some cities but their population sizes are lower. For example 91% UCs of Gujranwala (1.4 Million) house slums/ underserved areas but their population size is lower than Peshawar (1.5 Million) where 88% UCs house slums/ underserved areas. Similarly, 77% UCs of Islamabad house slums/ underserved areas but their population size is lower than Quetta where 44% UCs house slums/ underserved areas. From the above facts, it can be concluded that the spread of slums/underserved areas across UCs may not always be linked with greater population size.

4.2 Health Facilities

4.2.1 UCs with/without Health Facilities On the whole, 31% UCs do not have public health facilities. Within 05 cities of Punjab, the city that contributes the most to this percentage is Gujranwala with 70% of its UCs not having such facilities. This is followed by 54% UCs not having public health facilities in Faisalabad and 53% of Rawalpindi. On the other end of the spectrum lies Lahore, having only 04% of UCs devoid of any such facilities. About less than a quarter of the UCs in Peshawar (18%) and Quetta (20%) are found without health facilities. Of the 31% UCs where no public health facilities are found, residents are expected to visit and access services of health facilities located in other UCs. It is important to know that density of population and distances to and from health facilities are important considerations for making decision about the establishment of public health facilities. For example, the population density in Quetta is very low compared to that of 05 cities of Punjab. Similarly, distances to and from health facilities in Quetta are greater than distances of 05 cities of Punjab. 4.2.2 Health Facilities Vs UCs Overall, there are 578 Public Health facilities located in 430/626 UCs. The highest number of such facilities is located in Lahore (217) followed by Peshawar (110) and Quetta (63). Gujranwala (29) and Islamabad (30) has the lowest number of public health facilities. It is important to have at least one public health facility in each UC, which is not the case for 07 cities except Lahore where only 02 UCs remain without any public health facility.

Table 40: Population of Slums/Underserved

Cities

UCs With Slums/ Underserved

Population of total Slums/Underserved

# %

Faisalabad 86 76% 1,340,376

Gujranwala 58 91% 1,469,550

Lahore 127 77% 4, 650, 254

Multan 36 72% 923,520

Rawalpindi 44 73% 966,999

Islamabad 20 77% 379,640

Quetta 22 44% 712,404

Peshawar 85 88% 1,532,478

Total 478 76% 11,975,221

Table 41: UCs with/without Health Facilities

Cities # of UCs with Health

Facilities # of UCs without Health Facilities

Faisalabad 52 46% 61 54%

Gujranwala 19 30% 45 70%

Lahore 160 96% 6 4%

Multan 34 68% 16 32%

Rawalpindi 28 47% 32 53%

Islamabad 17 65% 9 35%

Quetta 40 80% 10 20%

Peshawar 80 82% 17 18%

Total 17 65% 196 31%

Table 42: Health Facilities Vs. UCs

Cities Total UCs # of Public Health Facilities in

Total UCs

Faisalabad 113 52

Gujranwala 64 29

Lahore 166 217

Multan 50 45

Rawalpindi 60 32

Islamabad 26 30

Quetta 50 63

Peshawar 97 110

Total 626 578

33

4.3 EPI Facilities

4.3.1 UCs with/without EPI Facilities Overall, 26% UCs do not have any EPI facilities. Within 05 cities of Punjab, the trend is mainly driven by Gujranwala with 72% UCs not having EPI facilities. On the other hand, Lahore is the only city in which all UCs have EPI facilities available within them. About half of the UCs of Rawalpindi (52%) is devoid of EPI facilities. 4.3.2 EPI Facilities Vs. Union Councils There are a total of 592 EPI facilities located in 461 UCs. Within 05 cities of Punjab, more than half of the (220) EPI facilities are located in Lahore whereas the lowest number of such facilities is found in Gujranwala (18). 165 UCs across eight cities are devoid of any EPI facilities. Highest number of UCs without EPI facilities is found in Gujranwala (72%), Rawalpindi (52%) and Faisalabad (45%). A small percentage of Peshawar (3%) and Quetta (18%) are devoid of any EPI facility while more than quarter of the UCs in Islamabad (31%) and Multan (32%) are devoid of EPI facilities. It is important to know that the total population of 08 cities is 24 Million and on average, each EPI facility has a load of 40540 persons. It is extremely important to improve the service delivery gap in the largest cities of Pakistan to improve the access of common people especially those residing in slums/underserved areas to EPI facilities. Although the average population per EPI facility in Quetta seems lowest but the distances and low population density requires more EPI facilities than the current number. 4.3.3 Outreach Vaccination Overall 98% UCs have outreach vaccination services available within them. Five cities of Punjab and Peshawar and Quetta have 100% outreach vaccination services available at the UC level. Only 62% UCs of Islamabad have outreach services available to them. It is important to know that 29% slums/underserved areas are devoid of any outreach vaccination services. It is important to assess the effectiveness of outreach vaccination from the percentage of unimmunized and under immunized children in slums/underserved areas (see results of coverage survey in slums/ underserved areas of 10 largest cities of Pakistan). 4.3.4 Cold Chain Overall, 98% EPI facilities have functional Ice Lined Refrigerators available within them. All EPI facilities located in five cities of Punjab, Quetta and Peshawar have functional Ice Lined Refrigerators available within them. In some instances, it is possible that the proper functionality of ILRs is disrupted by frequent power breakdowns.

Table 43: UCs with/without EPI Facilities

Cities UCs with EPI

Facilities UCs without EPI

Facilities



Lahore 165 99% 1 1%

Multan 34 68% 16 32%



Quetta 41 82% 9 18%

Peshawar 94 97% 3 3%

Total 461 74% 165 26%

Table 44: EPI Facilities Vs. UCs

Cities Total UCs # of EPI Facilities in Total

UCs

Faisalabad 113 67

Gujranwala 64 18

Lahore 166 220

Multan 50 45

Rawalpindi 60 29

Islamabad 26 24

Quetta 50 69

Peshawar 97 120

Total 626 592

Table 45: Outreach Vaccination Services Cities Availability of Outreach Vaccination Services

Faisalabad 113 100%

Gujranwala 64 100%

Lahore 166 100%

Multan 50 100%

Rawalpindi 60 100%

Islamabad 16 62%

Quetta 50 100%

Peshawar 97 100%

Total 616 98%

Table 46: Status of Functional ILR

Cities EPI facilities with Functional ILR

EPI facilities with Non Functional ILR



Lahore 220 100% 0 0%

Multan 45 100% 0 0%



Quetta 111 93% 9 8%

Peshawar 67 97% 2 3%

Total 579 98% 13 2%

34

4.4 Nutrition Services

4.4.1 Presence of Nutrition Services Overall, 50% UCs have nutrition services in 4 cities namely Multan (68%), Peshawar (66%), Faisalabad (56%) and Islamabad (50%). Nutrition services are not available in 37% UCs. This is primarily driven by Quetta (82%) and Gujranwala (70%) being devoid of such services. On the other extreme, all UCs of Lahore (100%) have nutrition services available within them.

4.4.2 Types of Nutrition Services Overall, there are four types of nutrition services being offered:

Fixed Sites

Temporary Sites

School Sessions

Sessions by LHWs 4.4.2a Fixed Sites Overall, half of the UCs of Multan (68%), Faisalabad (56%) and Rawalpindi (47%) have fixed nutrition services. Around quarter of the UCs of Islamabad (19%) have fixed nutrition site. A very small percentage of UCs in Quetta (2%) has these services available. None of the UCs of Peshawar has fixed nutrition sites available within it. 4.4.2b Sessions by LHWs Overall, 42% UCs have nutrition services by LHWs. More than half of the UCs of Lahore (87%), Peshawar (66%) and Rawalpindi (47%) have nutrition services by LHWs. Multan, Gujranwala and Faisalabad does not offer any nutrition services by LHWs. (Table 9 Annex 5). 4.4.2c School Sessions Three cities namely Lahore (13%), Quetta (7%) and Peshawar (2%) offer school nutrition sessions. None of the other city has school nutrition sessions. 4.4.2d Temporary Sites Only Quetta (18%) city have temporary nutrition sites available. None of the other seven cities have temporary sites for nutrition services. 4.5 Human Resources 4.5.1 Vaccinators The number of vaccinators to be deployed for each EPI facility is dependent on the type of health facility where the EPI facility in question is housed. Health facilities operating at a secondary or tertiary level have a higher number of vaccinators as these are expected to cater to a larger number of patients and caregivers. A total of 931 vaccinators are working within 592 EPI facilities. On average, there are 1.6 vaccinator available per EPI facility. Within Punjab, Lahore takes the lead with a total of 356 vaccinators followed by Peshawar (246) and Quetta (120) while the lowest number is contributed by Gujranwala having a merely 19 vaccinators and Rawalpindi having 29 vaccinators.

Table 47: Nutrition Services

Cities UCs with Nutrition

Services UCs without Nutrition

Services



Lahore 166 100% 0 0%

Multan 34 68% 16 32%


Islamabad 13 50% 13 50%

Quetta 9 18% 41 82%

Peshawar 64 66% 33 34%

Total 396 63% 230 37%

Table 48: Types of Nutrition Services

Cities Fixed Sites School Session

Sessions by LHWs



Lahore 7% 13% 87%

Multan 68% 0% 0%



Quetta 2% 18% 18%

Peshawar 0% 2% 66%

Total 26% 5% 42%

Only Quetta have (18%) temporary nutrition sites

Table 49: Number of Vaccinators

Cities Total EPI Facilities

# of Vaccinators in Total UCs

Faisalabad 67 75

Gujranwala 18 19

Lahore 220 356

Multan 45 45

Rawalpindi 29 29

Islamabad 24 41

Quetta 69 120

Peshawar 120 246

Total 592 931

35

4.5.2 Lady Health Workers Overall, 25% UCs remains uncovered by LHWs. There are total 3793 Lady Health Workers deployed in 75% UCs. Highest percentage of UCs uncovered by LHWs is in Rawalpindi (52%) and Islamabad (46%). A negligible percentage of UCs in Lahore (2%) and Multan (16%) are uncovered by LHWs. 4.5.3 Dengue Workers Overall, dengue workers are available in 92% UCs of 6 cities. 100% UCs of 05 cities of Punjab and Peshawar have dengue workers. Since dengue is not an issue for Quetta therefore, department of health have not deployed any dengue workers. Similarly in Islamabad, temporary staff is deployed during dengue seaso

Table 50: UCs Uncovered by LHWs

Cities Total # of

LHWs Total UCs Uncovered by LHW

Faisalabad 173 44 39%

Gujranwala 64 9 14%

Lahore 1335 3 2%

Multan 265 8 16%

Rawalpindi 135 31 52%

Islamabad 145 12 46%

Quetta 516 19 38%

Peshawar 1160 33 34%

Total 3793 159 25%

Table 51: Dengue Workers Cities UCs with Dengue Workers

Faisalabad 113 100%

Gujranwala 64 100%

Lahore 166 100%

Multan 50 100%

Rawalpindi 60 100%

Islamabad NA NA

Quetta 0% 0%

Peshawar 97 100%

Total 550 92%

36

Chapter 5 Status of EPI Facilities

59% EPI Facilities are

Without SoP

36% EPI Facilities have

Inadequate Seating

Capacity

14% EPI Facilities Work for

Less than 6 Hours


Without Toilets


Without Drinking

Water Facility

37

Chapter 5: Status of EPI Facilities

In Pakistan, vaccine service delivery for children and women is being offered through EPI facilities, outreach camps and mobile services according to the systems and procedures of each Provincial EPI Cell. The previous chapters describe the situation of slums/underserved areas and availability of health resources in the Union Councils of 08 largest cities of Pakistan. Chapter 4 clearly articulates that besides availability of health and EPI facilities at the Union Council levels, their access and utilization at the slum/underserved areas are very low. This chapter amplifies the situation of 422 EPI facilities located across largest cities of three provinces and Islamabad based on the physical assessment. The overall objectives of the assessment of EPI facilities were to know the strengths and weaknesses of the service delivery system and analyze correlations between coverage rates and strengths and weakness of the system. The physical assessment of 422 EPI facilities checked the following variables: 5.1 Infrastructure 5.1.1 Ownership of Buildings 5.1.2 Waiting Areas 5.1.3 Drinking Water 5.1.4 Toilets

5.2 System 5.2.1 Standard Operating Procedures 5.2.2 Working Hours

5.3 Equipment and Supplies 5.3.1 Ice Line Refrigerators 5.3.2 Supplies 5.3.3 Vaccines

5.4 Waste Management 5.4.1 Types of Practices

5.5 Human Resource 5.5.1 Vaccinators 5.5.2 Lady Health Visitors These EPI facilities have various levels i.e. some of them are EPI facility while some of them are either housed in Basic Health Units and or tertiary/secondary level hospitals. A small percentage of EPI facilities are housed in Private and or Welfare health facilities but run and managed by government. 5.1 Infrastructure

5.1.1 Ownership of Buildings Overall, 85% buildings of EPI facilities are owned by the government, while 15% facilities are either present in rented buildings or housed in private or welfare health facilities. 100% EPI facilities in Faisalabad and Rawalpindi are owned by the government. Majority of the EPI facilities of Quetta (93%), Lahore (94%), Islamabad (79%) and Peshawar (78%) are also owned by government, while the about half of the facilities in Gujranwala (50%) and Multan (57%) are housed in rented/ or private buildings.

50%

57%

78%

79%

93%

94%

100%

100%

85%

50%

43%

22%

21%

7%

6%

0%

0%

15%

GJR

MTN

PWR

IBD

QTA

LHR

RWP

FSD

Total

Rented/Housed in Private/Welfare Owned

Figure 4: Ownership Status of Buildings of EPI Facilities

38

Overall, out of the 15% EPI facilities, which are located in the rented buildings or in Private/welfare health facilities, 96% are run and managed by government. 100% EPI facilities in five cities of Punjab are run and administered by the government while 21% EPI facilities of Islamabad are located in privately owned hospital and 4% EPI facilities are housed in charity/trust set up. Whereas, 4% EPI facilities in Quetta and 2% EPI facilities in Peshawar are being run by a charity organization (Table 3 and Annex 6). 5.1.2 Waiting Areas The waiting areas of the EPI facilities were assessed for two main parameters, which include availability of adequate space and gender-segregated space for women. The cultural and religious requirements demand for a gender segregated waiting area especially for women caregivers. 5.1.2a Gender Mixed Waiting Areas

Two cities namely Peshawar and Quetta have relatively higher preferences for gender-segregated services. Overall, 59% EPI facilities do not have gender segregated waiting areas. Highest percentage of EPI facilities in Gujranwala (78%), Lahore (73%) and Faisalabad (65%) report about the unavailability of gender segregated waiting areas. Over half of the EPI facilities in Islamabad (54%), Peshawar (52%) and Quetta (52%) also report about unavailability of gender segregated waiting areas. Only Rawalpindi (42%) and Multan (40%) have relatively better situation where less than half of the waiting areas are not gender segregated. 5.1.2b Inadequate Seating Capacity Overall 36% EPI facilities have inadequate seating capacity in their waiting areas. Over 30% EPI facilities of seven out of eight cities report about inadequate seating capacity. Highest percentage of EPI facilities with inadequate seating capacity is found in Gujranwala (44%). Lowest percentage of inadequate seating capacity is found in EPI facilities of Islamabad (17%). In order to attract caregivers towards EPI facilities, it is extremely important to ensure caregiver friendly gender segregated adequate seating capacity.

5.1.3 Drinking Water Overall 35% EPI facilities do not have drinking water facility. Highest percentages of EPI facilities that report about unavailability of drinking water are found in three cities of Punjab (Gujranwala - 72%, Multan - 43%, Lahore - 42%) and Quetta (48%). A small percentage of Islamabad (21%) and Peshawar (25%) also report about unavailability of drinking water in their respective EPI facilities.

40% 42%

52% 52% 54%

65%

73%78%

59%

MTN RWP QTA PWR IBD FSD LHR GJR Total

17%

30%32%

37% 37% 37% 38%

44%

36%

IBD MTN RWP LHR QTA PWR FSD GJR Total

12%16%

21%25%

42% 43%48%

72%

35%

FSD RWP IBD PWR LHR MTN QTA GJR Total

Figure 10: Gender Mixed Waiting Areas

Figure 11: Inadequate Seating Capacity

Figure 12: Unavailability of Drinking Water

39

5.1.4 Toilets

5.1.4a Unavailability of Toilets Availability of useable toilets is extremely important for the patients and their attendants. Overall 26% of the total assessed EPI facilities report about unavailability of toilets. Highest percentages of EPI facilities that report about unavailability of toilets are in Rawalpindi (42%). The situation of Peshawar (21%) and Quetta (26%) is comparatively better. The trend varies across cities of Punjab as 100% EPI facilities of Faisalabad have toilet facilities but three cities namely Gujranwala (39%), Lahore (35%) and Multan (33%) report unavailability of toilets in their EPI facilities. 5.1.4b Gender Mixed Toilets From those EPI facilities where toilets are available, it is interesting to put a gender lens on them. Majority of the women in Pakistan feel more comfortable in using gender-segregated toilets. Because of the limited number of toilets in EPI facilities, majority of the toilets are gender mixed. Overall 31% of the total EPI facilities do not have gender-segregated toilets. Highest percentage of EPI facilities without gender-segregated toilets is found in Faisalabad (68%), Gujranwala (44%) and Peshawar (41%). Highest percentage of gender-segregated toilets is available in Islamabad (71%), Quetta (56%) and Multan (50%). Less than 40% toilets in EPI facilities of five out of eight cities are gender segregated. (Table 14 Annex 6). 5.1.4c Unusable Toilets

In EPI facilities where toilets are available 14% are not usable. Highest percentage of unusable toilets is found in Peshawar (27%), Multan (20%) and Gujranwala (17%). None of toilets of EPI facilities of Rawalpindi (0%) are unusable. Less than 15% toilets are unusable in EPI facilities of four cities namely Quetta (13%), Islamabad (9%), Lahore (8%) and Faisalabad (6%). The low usability of toilets is because of multiple factors including unavailability of water, filthiness or physical damage of toilet facility.

0%

8%

21%

26%

33%35%

39%42%

26%

FSD IBD PWR QTA MTN LHR GJR RWP Total

11%17% 19% 21%

25%

41%44%

68%

31%

RWP MTN QTA IBD LHR PWR GJR FSD Total

Gender Mixed Toilets

0%

6%8%

9%

13%

17%

20%

27%

14%

RWP FSD LHR IBD QTA GJR MTN PWR Total

Figure 5: Unavailability of Toilets

Figure 14: Gender Mixed Toilets

Figure 15: Unusable Toilets

40

5.2 Systems

5.2.1 Standard Operating Procedures Standard Operating Procedures (SoP) guide facility staff about the quality standards and help them avoid malpractices thus availability of SoP is a basic step towards its compliance. Overall SoPs are not available in 59% of the total assessed EPI facilities. Gujranwala (89%), Islamabad (83%) and Quetta (81%) have the highest percentage of EPI facilities without SoPs. The lowest percentage of EPI facilities in Faisalabad (21%), report unavailability of SoPs.

5.2.2 Working for Less than 6 Hours The EPI facilities usually work for 08 hours a day. Two hours are dedicated for the working of vaccinators for record keeping while 06 hours are dedicated for the provision of vaccination services. Overall 14% of the assessed EPI facilities work for less than 6 hours a day. EPI facilities of six out eight cities report about their working for less than 6 hours per day. Highest percentage of EPI facilities in Quetta (69%) work for less than 6 hours. About a quarter of EPI facilities of Islamabad also report working for less than 6 hours a day. A very small percentage of assessed EPI facilities of Gujranwala (6%), Lahore (2%), Rawalpindi (5%) and Peshawar (9%) report about their working duration for less than 6 hours a day.

5.3 Equipment and Supplies

5.3.1 Non Functional Ice Lined Refrigerators Overall only 3% Ice lined refrigerators are found non functional in total assessed EPI facilities. City wise comparison reflects a small percentage of EPI facilities in Rawalpindi (11%) and Peshawar (08%) and Quetta (04%) with non-functional ILR. EPI facilities of five cities have functional ILR. There are multiple reasons of non-functional ILR such as technical damage or power break down. It is important to ensure proper cold chain in all available EPI facilities to continue uninterrupted quality provision of vaccine service delivery. 5.3.2 Availability of Supplies As per SoPs, EPI facilities are supposed to have full stock of vaccines and its related supplies for ensuring uninterrupted vaccination service provision. Availability of the important supplies namely ice packs, vaccine carrier, safety boxes and auto disable syringes were checked while assessing 422 EPI facilities.

21%

51%55%

63%67%

81% 83%89%

59%

FSD LHR PWR RWP MTN QTA IBD GJR Total

0% 0% 2%5% 6%

9%

25%

69%

14%

MTN FSD LHR RWP GJR PWR IBD QTA Total

0%

0%

0%

0%

0%

4%

8%

11%

3%

GJR

MTN

FSD

LHR

IBD

QTA

PWR

RWP

Total

Figure 16: Standard Operating Procedures

Figure 17: Working for Less than Six Hours

Figure 6: Non Functional ILR

41

5.3.2a Ice Packs Overall 3% EPI facilities report about shortage of ice packs from five cities. These are Rawalpindi (11%), Quetta (7%), Multan (10%), Peshawar (2%) and Lahore (2%). 5.3.2b Vaccine Carrier Overall 2% EPI facilities report about shortage of vaccine carrier from four cities. These are Rawalpindi (11%), Peshawar (1%), Quetta (2%) and Lahore (2%). 5.3.3c Safety Boxes Overall 1% EPI facilities report about shortage of safety boxes from only one city Peshawar (3%). All other facilities have safety boxes available. 5.3.4d Auto disable Syringes Overall 4% EPI facilities report about shortage of auto disable syringes from four cities infrequently. These are Rawalpindi (21%), Peshawar (9%), Gujranwala (6%) and Islamabad (4%).

5.3.2b Vaccines In order to ensure, uninterrupted vaccination service provision, it is important to ensure sufficient stock of vaccine at all times. Although majority of EPI facilities report no shortage of vaccine, a small percentage report about frequent and infrequent shortage of vaccines. Overall only 1% EPI facilities report frequent shortage of vaccines from Quetta (6%) and Peshawar (2%) only and infrequent shortage of vaccine from four cities namely Gujranwala (83%), Quetta (29%) and Peshawar (14%).

5.4 Waste Management

Waste management of supplies is extremely important and it has to be done according to the laid down SoP to avoid the misuse of syringes. Majority of the EPI facilities (98%) report burning and burial of the waste as a waste management practice. A small percentage of EPI facilities in Multan (20%) and Lahore (2%) report about the waste pick up system by Waste Management Company (WMC) vehicle.

79%

91%

94%

96%

100%

100%

100%

100%

96%

100%

97%

100%

100%

100%

100%

100%

100%

99%

89%

99%

100%

100%

98%

100%

100%

98%

98%

89%

98%

100%

100%

93%

90%

100%

98%

97%

RWP

PWR

GJR

IBD

QTA

MTN

FSD

LHR

Total

Auto Disable Syringes Safety BoxesVaccine Carrier Ice Packs

0% 0% 0% 0%3%

14%

29%

83%

12%

0% 0% 0% 0% 0% 2%6%

0% 1%

RWP MTN LHR IBD FSD PWR QTA GJR Total

Sometimes Shortage Mostly Shortage

80%

98%

100%

100%

100%

100%

100%

100%

98%

20%

2%

0%

0%

0%

0%

0%

0%

2%

MTN

LHR

GJR

RWP

FSD

IBD

QTA

PWR

Total

Waste Management

WMC Vehicle

Burn & Buried

Figure 19: Availability of Supplies

Figure 20: Shortage of Vaccine

Figure 21: Waste Management Practices

42

5.5 Human Resource

5.5.1 Vaccinators Overall 99% EPI facilties report availability of one or more vaccinators in seven out of eight cities. The number of vaccinator for each EPI facility varies but at least one vaccinator is available in 100% assessed EPI facilities. A small percentage of EPI facilities of Islamabad (12%) do not have vaccinators. It is important to know that the number of vaccinators for each facility varies according to its administrative status and population of the UC where this facility is located. EPI facilities located in secondary or tertiary hospitals have more than one vaccinator hence large number of children can be catered on a daily basis.; 5.5.2 Lady Health Visitors The deployment of Lady Health Visitors (LHVs) is done according to the administrative level of each health facility. EPI facilities housed in secondary and tertiary hospitals and Basic Health Unit may have deployment of LHVs but an independent EPI Facility may not have deployment of LHVs under the administrative system. Primary purpose of the LHV in any of the health facilities is to offer maternal child health care, but they are also made responsible for the vaccination as well. 39% EPI facilities do not have LHVs hence maternal health services are not available in these EPI facilities. Highest percentage of LHVs in EPI facilities is found three cities namely Islamabad (79%), Faisalabad (76%) and Rawalpindi (74%). Lowest percentage of EPI facilities with LHVs is found in Gujranwala (22%).

22%

57% 59% 60%64%

74% 76% 79%

61%

GJR LHR QTA MTN PWR RWP FSD IBD Total

88%

100% 100% 100% 100% 100% 100% 100%99%

IBD QTA GJR RWP MTN FSD LHR PWR Total

Figure 22: Availability of Vaccinators

Figure 23: Availability of Lady Health Visitors

43

Chapter 6 Situation in Super High Risk Union Councils

88% Super High Risk UCs

are With Slums/

Underserved Areas


Areas Reported Non

Presence of EPI

Facility

56% Slum/ Underserved

Areas are Not

Covered by LHWs

41% Children in

Slums/Underserved

are Partially

Vaccinated

21% Children in

Slums/Underserved

Areas Are Zero Dose

44

Chapter 6: Situation in Super High Risk Union Councils

The detailed analysis of union councils for polio high risk segregates 40 UCs as Super High Risk due to certain factors, which requires context specific planning for improving the situation. 32 of the 40 UCs are located in three largest cities of Pakistan namely Karachi, Peshawar, Quetta. This chapter compiles information for Super High Risk UCs (SHRUCs) extracted from the following three sources: a. Profiling of slums/underserved areas held in 10 largest cities of Pakistan (Chapter 3); b. Coverage survey in slums/underserved areas of 10 largest cities of Pakistan. The report

for coverage survey held in slums/underserved areas of 10 largest cities of Pakistan exist separately.

c. Data of health resources of SHRUCs collected from the department of health (Chapter 4) The data for profiling of slums and SHRUCs of Karachi is extracted from the separate report on profiling of slums of Karachi and Hyderabad81. The objective of this chapter is to present the key highlights of SHRUCs with the above stated data sets. The following variables are analysed and presented: 6.1 Health Resources in SHRUCs 6.1.1 Number Health Facilities 6.1.2 SHRUCs with/without Health Facilities 6.1.3 Number of EPI Facilities 6.1.4 Number of Vaccinators 6.1.5 SHRUCs with/without EPI Facilities 6.1.6 SHRUCs with/without Outreach Vaccination 6.1.7 SHRUCs with/without LHWs 6.2 Slums/Underserved Areas Located in SHRUCs 6.2.1 SHRUCs with/without Slums/Underserved Areas 6.2.2 Slums/Underserved Areas in SHRUCs 6.2.3 Types of Residents in Slums/Underserved Areas 6.2.4 Population of Slums/Underserved Areas 6.2.5 Slums/Underserved Areas Uncovered by LHWs 6.2.6 Slums/Underserved Areas with/without Health Facilities 6.2.7 Slums/Underserved Areas with/without EPI Facilities 6.2.8 Slums/Underserved Areas with/without Outreach Vaccination 6.3 Status of Childhood Vaccination 6.3.1 Sample Size 6.3.2 Retention of Vaccination Card 6.3.3 Fully Immunized 6.3.4 Partially Vaccinated 6.3.5 Zero Dose 6.3.6 Reasons of Zero Dose The above stated variables are analysed specifically for 32 SHRUCs located in three cities namely Peshawar, Quetta and Karachi.

6.1 Health Resources of SHRUCs

6.1.1 Health Facilities 32 SHRUCs have 45 health facilities. When number of health facilities is compared with the number of SHRUCs, it shows highest number of health facilities in Karachi where 8 SHRUCs

81 Profiling of slums in Karachi and Hyderabad was done in 2017

Table 52: Health Facilities in SHRUCs Cities Number of SHRUCs Number of Health Facilities

Peshawar 18 22

Quetta 6 9

Karachi 8 14

Total 32 45

45

have 14 health facilities. Quetta has the lowest number of health facilities where 6 SHRUCs have only 9 health facilities. 6.1.2 SHRUCs with/without Health Facilities Although 45 health facilities are found for 32 UCs but a deeper analysis reflects 16% SHRUCs are without any health facility. About a quarter of the SHRUCs of Karachi (33%) and Peshawar (20%) are found without Public health facilities. None of the SHRUCs of Quetta are found without health facility. 6.1.3 EPI Facilities 32 SHRUCs have 55 EPI facilities. When number of EPI facilities is compared with the number of SHRUCs, it shows highest number of EPI facilities in Karachi where 8 SHRUCs have 22 EPI facilities. Peshawar has lowest number of health facilities where 18 SHRUCs have 24 EPI facilities while 6 SHRUCs of Quetta have only 9 EPI facilities. Number of EPI facilities per UC is determined according to the population size and distances to and from residential areas. 6.1.4 SHRUCs with/without EPI Facilities 55 EPI facilities are found for 32 SHRUCs. None of SHRUCs are without any EPI facility. It would be interesting to analyse the following two factors to assess the appropriateness of the number of EPI facility per UC: (a) Population of each UC; (b) distance of residential areas to and from EPI facility location and duration. 6.1.5 Number of Vaccinators Overall 79 vaccinators are working in 55 EPI facilities located in 32 SHRUCs. Highest number of vaccinators is found in EPI facilities of Peshawar (47) while lowest number of vaccinators is found in EPI facilities of Karachi (14). 6.1.6 SHRUCs with/without Outreach Vaccination None of the SHRUCs of three cities are found without outreach vaccination. The low vaccination coverage and polio high risk factor in these SHRUCs imply either service delivery has some gaps or caregivers are unaware of importance of vaccination and component on demand generation is weak. 6.1.7 SHRUCs with/without LHWs Coverage Overall 78% SHRUCs have deployment of LHWs while a small percentage of SHRUCs in Quetta (33%) and Peshawar (28%) are without deployment of LHWs. LHWs are important health resource which may play an important role in demand generation and reduce number of refusals through their house to house mobilization.

Table 53: SHRUCs with/without Health Facilities

Cities SHRUCs with Health Facilities

SHRUCs without Health Facilities

Total SHRUCs

Peshawar 15 3 18

Quetta 6 0 6

Karachi 6 2 8

Total 27 5 32

% 84% 16% 100%

Table 54: Number of EPI Facilities in SHRUCs Cities Number of SHRUCs Number of EPI Facilities

Peshawar 18 24

Quetta 6 9

Karachi 8 22

Total 32 55

Table 55: SHRUCs with/without EPI Facilities Cities SHRUCs with

EPI Facilities SHRUCs without EPI Facilities

Total SHRUCs

Peshawar 18 0 18

Quetta 6 0 6

Karachi 8 0 8

Total 32 0 32

% 100% 0% 100%

Table 56: Number of Vaccinators Vs. Number of EPI Facilities

Cities Number of EPI Facilities

Number of Vaccinators

Peshawar 24 47

Quetta 9 18

Karachi 22 14

Total 55 79

Table 57: SHRUCs with/without Outreach Vaccination Cities SHRUCs with

Outreach SHRUCs without Outreach

Total SHRUCs

Peshawar 10 0 18

Quetta 6 0 6

Karachi 8 0 8

Total 32 0 32

% 100% 0% 100%

Table 58: SHRUCs with/without LHWs Coverage

Cities SHRUCs with LHWs

SHRUCs without LHWs

Total SHRUCs

Peshawar 13 5 18

Quetta 4 2 6

Karachi 8 0 8

Total 25 7 32

% 78% 22% 100%

46

6.2 Slums/Underserved Areas

6.2.1 SHRUCs with/without Slums/Underserved Areas Overall 88% SHRUCs house slums/underserved areas. A small percentage of SHRUCs in Peshawar and Quetta do not have slums/underserved areas while 100% SHRUCs of Karachi are with slums/underserved areas. It is important to know the number of slums/underserved areas and target population residing in these areas for effective planning. 6.2.2 Slums/Underserved Areas in SHRUCs 28 SHRUCs house 299 slums/underserved areas. Highest number of slums/underserved areas is found in Quetta (120) followed by Peshawar (102). The concentration of slums/underserved areas in relation to the number of SHRUCs shows highest concentration in Quetta where 120 slums/underserved areas exist in 6 UCs only while Karachi has the lowest concentration where 77 slums exist in 8 UCs. It is important to know that the size of slums/underserved areas varies in each city. A city may have a smaller number of slums/underserved areas but high population size. For example Karachi has the lowest number of slums (77) while population size of slums is highest amongst all three cities (6.2.4). 6.2.3 Types of Residents82 in Slums/Underserved Areas Majority of the residents of slums/underserved areas are permanent settlers (70%). More than quarter of the residents of slums/underserved areas in Peshawar (29%) are temporary displaced and another 9% residents belong to other Nationalities. Similarly slums/underserved areas of Quetta have highest percentage for permanent settlers (86%) and lowest percentages for temporary displaced (7%) and residents belonging to other Nationalities (7%). 6.2.4 Population of Slums/Underserved Areas Approximate population of slums/underserved areas is about 1 Million. Although lowest number of slums/underserved areas are found in 8 SURUCs of Karachi but the population size is highest here. The population size of slums/underserved areas of Peshawar and Quetta have 0.2 Million people. 6.2.5 Slums/Underserved Areas Uncovered by LHWs Overall 44% slums/underserved areas are covered by LHWs with highest percentage in Peshawar (52%). Almost 70% slums/underserved areas in Quetta and 45% slums/underserved areas in Karachi are not covered by LHWs.

82 This information is not available for Karachi

Table 59: SHRUCs with/without Slums/Underserved Cities SHRUCs SHRUCs with

Slums/ Underserved

SHRUCs without Slums/ Underserved

Peshawar 18 15 3

Quetta 6 5 1

Karachi 8 8 0

Total 32 28 4

% 100% 88% 12%

Table 60: Slums/Underserved Areas in SHRUCs


Peshawar 102 0 102

Quetta 110 10 120

Karachi 77 0 77

Total 289 10 299

Table 61: Types of Residents in Slums/Underserved

Cities Permanent Temporary Displaced

Other Nationality

Peshawar 62% 29% 9%

Quetta 86% 7% 7%

Total 70% 21% 9%

Karachi This information was not collected while profiling slums

Table 62: Population of Slums/Underserved Areas


Peshawar 281,813 0 281,813

Quetta 177,684 43,480 221,164

Karachi 510,993 0 510,993

Total 970,490 43,480 1,013,970

Table 63: Slums/Underserved Areas Uncovered by LHWs

Cities LHW Covered LHW Uncovered Total

Peshawar 52% 48% 100%

Quetta 30% 70% 100%

Karachi 55% 45% 100%

Total 44% 56% 100%

47

6.2.6 Slums/Underserved Areas with/without Health Facilities Majority of the slums/underserved areas do not mention about presence of health facilities beyond 2 kilometers radius (94%). A very small percentage in slums/underserved areas of Peshawar (2%), Quetta (3%) and Karachi (14%) mention about presence of health facilities within 2 kilometers radius. 6.2.7 Slums/Underserved Areas with/without EPI Facilities Majority of the slums/underserved areas are without EPI facilities (92%). Residents of 92% slums/underserved areas are expected to travel beyond 2 kilometers to access EPI facilities. A small percentage of slums/underserved areas in Peshawar (5%), Quetta (7%) and Karachi (13%) report about presence of EPI facilities within 2 kilometers radius. 6.2.8 Slums/Underserved with/without Outreach Vaccination Majority of the slums/underserved areas report that they are covered for outreach vaccination 81%). A small percentage of slums/underserved areas in Quetta (27%) and Karachi (31%) report that they are not covered for outreach vaccination.

6.3 Status of Childhood Vaccination

The status of childhood vaccination for slums/underserved areas located in SHRUCs was an integral part of larger coverage survey held in 10 largest cities of Pakistan. A separate report exists for the results of coverage survey. Specific results of childhood vaccination are presented are extracted only for slums/underserved areas of 32 SHRUCs. 6.3.1 Retention of Vaccination Card Overall vaccination card retention is 30% with higher percentage of card retention in boys (54%) compared to girls (46%). Highest card retention is found in slums/underserved areas of Karachi (41%) and lowest card retention is found in slums/underserved areas of Quetta (26%). 6.3.2 Fully Immunized Overall 38% children are found fully immunized based on records and recall basis. Higher percentage of boys (54%) is found fully immunized compared to girls (46%). Highest percentage of fully immunized children is found in slums/underserved areas of Karachi (45%). Lowest percentage of fully immunized children is found in Quetta (21%).

Table 64: Slums/Underserved with/without Health Facilities

Cities With Health Facilities

Without Health Facilities

Total


Quetta 3% 97% 100%

Karachi 14% 86% 100%

Total 6% 94% 100%

Table 65: Slums/Underserved with/without EPI Facilities

Cities With EPI Facilities

Without EPI Facilities

Total


Quetta 7% 93% 100%

Karachi 13% 87% 100%

Total 8% 92% 100%

Table 66: Slums/Underserved with/without Outreach

Cities With Outreach Without Outreach Total

Peshawar 100% 0% 100%

Quetta 73%% 27% 100%

Karachi 69% 31% 100%

Total 81% 19% 100%

Table 67: Retention of Vaccination Card

Cities Girls Boys Total


Quetta 50% 50% 26%

Karachi 46% 54% 41%

Total 46% 54% 30%

Table 68: Fully Immunized (Records+ Recall)



Quetta 49% 51% 21%

Karachi 43% 57% 45%

Total 46% 54% 38%

48

6.3.3 Partially Vaccinated Overall 41% children are found partially vaccinated. Gender difference was not significant for partially vaccinated children in Peshawar and Quetta. In slums/underserved areas of Karachi, a higher percentage of girls (54%) are found partially vaccinated compared to boys (46%). 6.3.4 Zero Dose Overall 21% children are found having no antigens administered. Highest percentage of zero dose are found in slums/underserved areas of Quetta (27%) and lowest percentage of zero dose are found in slums/underserved areas of Karachi (11%). 6.3.5 Reasons of Zero Dose Majority of the mothers (48%) state non-permission as one of the major reasons for not getting their children immunized. City wise analysis of reasons reflects highest intensity of non-permission in slums of Karachi (71%) compared to Quetta (36%) and Peshawar (54%). Intensity of other reasons varies for each city. Other reasons include ‘fear of side effects’, ‘no time for vaccination’ and unaware of vaccination timings etc. All other reasons stated by mothers are highlight low levels of awareness about the importance of immunization.

Table 69: Partially Vaccinated (Records+ Recall)



Quetta 49% 51% 52%

Karachi 54% 46% 44%

Total 50% 50% 41%

Table 70: Zero Dose



Quetta 46% 54% 27%

Karachi 50% 50% 11%

Total 49% 50% 21%

0%

1%

1%

5%

10%

29%

54%

Unaffordability ofTransport Cost

Unaware of Vaccination

Fear of Injection

Unaware of VacinationTimings

No time for Vaccination

Fear of Side Effects

No Permission

Peshawar

3%

10%

11%

12%

16%

17%

36%

Fear of Injection






No Permission

Quetta

0%

0%

4%

21%

21%

46%

71%




Fear of Injection



No Permission

Karachi

Figure 24: Reasons of Zero Dose

49

Chapter 7 Conclusion and Recommendations

No Time for Vaccination

Rasheeda, a 27 year old is a mother of Murad (22 months old) lives in a small Kacha house of one room with 10 family members (5 males and 5 females) in Basti Kili Balochabad of Chilton town of Quetta Balochistan. Some part of the Basti is situated in Zarghoun town as well. The other residents of the Basti are mostly Pashtun like her family. There are around 50 households in her Basti with mixed Kacha and Pacca housing structures. Majority of the male population of this Basti work on daily wages. The financial situation of the residents are not good and many families face the situation of only one meal per day due to the unavailability of the wages in different seasons. The hygiene condition of Basti is very poor. Mostly the drains are open and filthy and water is over flowing from the drains. The residents feel difficulty while passing through the street due to the drains water. The toilets also have traditional pits and dirty water mixed in the drains that caused more smell in the area. Small children play in the streets that are very harmful for their health. Although the households’ latrines are available inside the houses but small children often urinate in streets as well. There is also no solid waste management system in the Basti. Residents throw their waste in nearby plot. There is no health center or lady health worker in Basti.

“There is no health center in our Basti and its surroundings and We never saw any LHW in our area. Many of the mothers in our Basti do not have any knowledge about vaccination. My husband is also against the vaccination. We and our forefathers were grown without any vaccination and are healthier than today’s children”.

It is very unfortunate that Murad is not alone in this case there are 15 other children of his age in the Basti who never got any dose of vaccination.

50

Chapter 7: Conclusion and Recommendations

7.1 Conclusion

During 1950-1990, a significant proportion of the slums were formed, a period of rapid urbanization within the country. Even though a high proportion of these vulnerable areas are registered and have Pacca housing structures, a critical analysis of information gathered through profiling reveals that residents of such areas live in despicable conditions with minimal access to basic amenities such as proper sanitation and waste disposal management systems. A significant proportion, especially those residing in slums as compared to those living in underserved areas, have Kacha or Kacha-Pacca (mixed) housing structures in place, thereby making them more vulnerable to unfavorable weather conditions. Regardless of such poor conditions, a significant proportion of the residents have been residing in such areas for more than 2 years with only a negligible percentage of population being temporarily displaced or belonging to other nationalities. The presence of toilets in such areas is common, with only a very minute percentage of slums/underserved areas not having them. With respect to the types of toilets available, nearly half of the available toilets are connected with street drain and the other half is a traditional/open pit toilet. In areas where toilets are not available within their private abode, residents have to rely on other sources for defecation including using neighbor’s toilets, using public toilets or in instances where even these options are unavailable, ultimately resorting to open defecation. The lack of adequate solid and liquid waste disposal systems is commonplace, with a significant proportion of these areas having filthy and choked drains even where they do happen to exist. Dumping of waste on empty plots and streets is a practice adopted by nearly half of the areas surveyed with the other half reporting heavy reliance on government/WMC vehicles for proper waste disposal. Government water supply for domestic consumption purposes is available in only a quarter of slums/underserved areas with the remaining areas resorting to using ground water and acquiring water from tankers. A quarter of slums/underserved areas surveyed did not have any schools available shedding light on the dismal reality that children residing in such areas have to cover long distances by foot to gain education or, in a starker scenario, end up not getting educated at all. Health facility assessments reveal that about a third of the UCs of the 8 cities surveyed are devoid of public health facilities. Even in UCs where these facilities along with EPI facilities are present, the available resources to immunize children are inadequate and fall short of the prerequisite needed to meet the population’s vaccination needs. Furthermore, a very small percentage of these facilities are located within slums/underserved areas highlighting the fact that access to such facilities is limited to those who are most in need of utilizing such facilities’ services. Coupled with financial hardship, lack of accessibility to health facilities plays a pivotal role in resulting low immunization coverage rates of such areas. Nearly half of the UCs has nutrition services available within them with the highest percentage of such services being provided by LHWs followed by fixed nutrition services. Along similar lines, even in areas where EPI facilities are present, they lack the required resources and services to meet the population’s vaccination needs. More than half of the facilities surveyed lack gender segregated waiting areas and gender segregated toilets. This is a cause of concern, especially in provinces such as Peshawar and Quetta where female caregivers may be considerably discouraged to get their children vaccinated due to the lack of such facilities. More than half of these EPI facilities do not have SoPs available when checked at the time of visit indicating the crucial need for an adequate monitoring system to be in place. Even though vaccinators are available in nearly all facilities, LHVs, on the other hand, are available in nearly 60% of facilities only. This proves to be a discouraging factor for female caregivers to visit such facilities and to get their children immunized. In order to counter this problem, it is imperative that the number of LHVs be increased so that their services can be provided to those in need.

51

7.2 Study Limitations

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.

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.

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.

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

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

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.

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

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.

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.

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

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.

7.3 Recommendations

The following recommendations are made according to the gaps in health resources and coverage rates in slums/underserved areas. 7.3.1 Health Facilities

Improve access to health facilities by ensuring availability of health and EPI facilities according to the population size and access of majority of the residents.

Improve the availability and accessibility of health and EPI facilities for residents of slums/underserved areas. It is important to utilize the private sector health facilities for improving the access of slums/underserved areas to vaccination services.

7.3.2 Nutrition

Add component of Nutrition services in the current set of health and EPI facilities. This would economize the costs and multiply the impact of vaccination services.

Include topics like balanced diet, assessment of nutrition levels in children and mothers as part of the regular job of LHWs and vaccinators. This would help in enhancing the effectiveness of LHWs and vaccinators working.

52

7.3.3 EPI Facility

Ensure Standard Operating Procedures are updated according to current changes in the system and practices and that the staff is trained and followed up for its adherence.

Standard Operating Procedures is a guiding document for maintaining quality standards for running and managing the EPI facilities. It is extremely important to maintain quality standards according to approved Standard Operating Procedures, which will keep facilities working, more smooth, standardized and regular to attract more caregivers. There is an immediate need to ensure provision of Standard Operating Procedures and its compliance in all fixed EPI and health facilities.

Provide gender specific infrastructure facilities in buildings of EPI facilities. For example, women and men specific waiting areas with adequate seating capacity.

Ensure availability of drinking water, women and men specific functional, clean toilets to facilitate and encourage caregivers for visiting the EPI facilities particularly females.

Ensure timely availability of vaccines and vaccine supplies without any interruption to vaccination services.

7.3.4 Flexibility of Timings

Reconsider total timings and duration for offering vaccination services according to the preference of caregivers. Either introduce flexible hours for the outreach vaccination services according to the availability of residents of slums/underserved areas or introduce double shift system for vaccination services in EPI facilities and ensure availability of vaccination for extended hours as well.

7.3.5 Accountability

Ensure strict accountability and performance management system for the staff of EPI facilities. The EPI facility must operate for 06 hours per day consecutively for 5 days a week.

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

Offer periodic performance-based incentives to vaccinators to improve effectiveness of outreach vaccination services.

7.3.6 Outreach Vaccination

Ensure availability of outreach vaccination services in 100% slums/underserved areas.

Undertake awareness raising sessions about the existence and availability of the public health facilities and importance of its utilization.

Create permanent outreach vaccination points in or near slums/underserved areas. Health houses of LHWs can also be transformed into outreach vaccination points.

7.3.7 Health Work Force

Ensure all EPI facilities have vaccinators according to its workload. It is a missed opportunity for those children who happen to visit the facilities but go without any vaccination due to unavailability of the vaccinator.

Ensure timely availability of vaccines and vaccine supplies without any interruption to vaccination services

Facilitate vaccinators in preparing realistic micro plans and covering children living in both planned and unplanned areas (slums).

Create system for tracking new born and moving population to prepare realistic micro plans.

Guide LHWs about their awareness raising topics on a monthly basis.

Ensure deployment of LHVs in 100% EPI facilities as LHVs offer multiple benefits because of their qualifications and gender. They provide maternal child health care, services for safe delivery and vaccination to women and children. The cultural practices of Pakistan demand for women friendly services in which gender of the vaccinator is one such service, which may

53

attract women caregivers. Presence of LHVs encourages female caregivers to access EPI facilities not only for childhood vaccination but also for maternal child health care.

Ensure administration of vaccination in private health facilities, which offer MNCH services.

Ensure child registry as part of micro planning. 7.3.8 Community Engagement

Create a support structure in the form of influencers and religious leaders for mobilizing the hard-core refusals of childhood vaccination.

Organise residents of slums/underserved areas into an organised group to become a support tier for facilitating mobilization of caregivers during outreach vaccination.

Facilitate LHWs in raising awareness levels of caregivers on importance of childhood immunization as a priority.

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

Ensure announcement and positioning of Kit Station through community engagement. 7.3.9 Practical vs. Strategic Needs

Coordinate and combine vaccination services together with public and private welfare initiatives that contribute to improvements in economic conditions of urban poor. This would directly contribute to an increase in coverage rates as this addresses their practical as well as strategic problems.

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 as this addresses their practical as well as strategic problems.

7.3.10 Water

The containers used for the storage of water are very dirty and open. Most of these containers become breeding places for dengue mosquitoes. Establish regular water supply system in slums/underserved areas to avoid contamination as well as prevent any breeding place for dengue mosquitoes.

7.3.11 Household Toilets

Although majority of the slums are registered even then a large majority of them do not have access to proper sewerage system. Any outbreaks due to unhygienic conditions may affect the residents of entire city of Islamabad. Engage CSOs for introducing safe sanitation in slums/underserved areas.

7.3.12 Waste Management

The solid waste is thrown in either streets and or on empty plots in majority of the slums/underserved areas. Streets are playing area for children and make them highly vulnerable to catch preventable diseases. Provide solid waste management system in slums/underserved areas as part of preventing diseases and outbreaks.

7.3.13 Registration of Slums

36% slums are unregistered or illegal; this lack of official recognition makes these communities prone to evictions and deprived of basic facilities. Share list of unregistered slums to Kachi Abaadi Cells and Deputy Commissioner Offices and advocate them to regularise them. The provision of secure tenure for slum dwellers is a prerequisite to receiving delivery of basic services.

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Annex 1: Questionnaire for Group Discussion in Slums/Underserved Areas

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 4. Islamabad

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 Union Council? If there is no OLD name, type X

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

BS09 Is this a 1. Slum 2. Underserved area

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 – check the evidence. If any utility bill is available in the name of the area, this can be treated as evidence 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?

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

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

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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? 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. Are you aware of transport services offered by the government for any health related emergencies? 1. Yes 2. No

HF11a. Are you aware of 1122 by the government to respond to any domestic accidental emergency? 1. Yes 2. No

HF11b. Are you aware of 1038 by the government to respond to emergency related to the situation of pregnant women? 1. Yes 2. No

HF12.

Do Lady Health Workers work in this slum or underserved area? If the answer to this question is no then skip questions from HF13a to HF14f 1. Yes 2. No

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

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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 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 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

PART F & G

WA01

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. Tube wells 5. Other

WA02 If acquire domestic 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 exist in any of the houses of this slum or underserved area, please specify how many traditional pits toilets 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 exist 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

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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

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 Pacca type of infrastructure as the main residential area of the household? If yes then enter answer in number only. If there are no Pacca 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 Pacca 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

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 ED03a 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

PART K

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CSO01.

Are there any not for profit registered welfare or charity organisation working in this slum or under served area (NGOs-CSOs)? If the answer to this question is no then skip questions from CSO02 and CSO03. 1. Yes 2. No

CSO02 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

CSO03 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

CSO04

Are there any informal groups or committee working in this slum or underserved area? If answer to this question is no then skip question CSO05 1. Yes 2. No

CSO05

Do the informal groups/committees include the following. Skip this question if the answer to the question CSO04 is no 1. Health committee 2. School committee 3. Masjid/church committee 3. Jirga or Punchait 4. Zakat committee 5. Unregistered Community Based Organisation 6. If other than stated above then explain in meaningful text in correct spellings

CSO06a

Are there any public welfare schemes or initiatives by government? If answer to this question is no then skip questions CSO06b, CSO06c, CSO06d, CSO06e, CSO06f 1. Yes 2. No

CSO06b Does the government provide a loan scheme? Skip this question if the answer to the question CSO06a 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 CSO06a is no 1. Yes 2. No

CSO06e

Does the government provide a vocational skills scheme? Skip this question if the answer to the question CSO06a 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.

Please enter names and mobile phone numbers of participants of this group discussion (minimum three names and numbers required).

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

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

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

59

Annex 2: Questionnaire for Compiling Health Resource in Union Councils

BASIC INFORMATION: This questionnaire is to be filled in through individual interview of district health officer or district EPI coordinator

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

BS 02. Name of Interviewer

BS 03. Signature of Interviewer

BS 04. Name of Province:

BS 05. Name of District:

BS 06. Name of Town / Tehsil:

BS 07. New Name of Union Council:

TEHSIL/TOWN INFORMATION

TI 01. How many Union Councils are in this city? Please include all towns of this city.

Number…………………………..

TI 02. Enlist new and old names and number of all the Union Councils of this city for each town

# 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

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

# Names of Union Council List of Public Health Facilities

HF 02. How many Public 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 04. How many Lady Health Worker are currently active in each Union Council?

# Names of Union Council List of Lady Health Workers

HF 06. Is Dengue staff working in union council 1. Yes 2. No

HF 7. 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…………………

VACCINATION

VA 01. How many Fixed EPI Facilities (Vaccination centres) 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 centres)?

# Names of Union Council

Public Fixed EPI Facilities

Private Fixed EPI Facilities

Welfare Fixed EPI Facilities

Any Other Type of Fixed EPI Facilities

60

Functional Non Functional

Functional

Non Functional

Functional

Non Functional

Functional Non Functional

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 centre) established by other than public sector organisation

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Annex 3: Questionnaire for EPI Facility Assessment Objective: This questionnaire will be used for the assessment of fixed EPI Facility and undertake group interview with the facility team.

# Identification Answer and code

ID1 Date of assessment

ID2 Name of assessor

ID3 Signature of assessor

ID4 Name of Province

ID5 Name of District

ID6 Name of Town (or Tehsil)

ID7 Name of the EPI Facility

ID8 Record longitude and latitude of the fixed EPI Facility ……. Longitude ……. Latitude

ID9 Take photo of the fixed EPI Facility 1 – Photos taken 2 – Not taken

# Infrastructure

IM1 What is the type of building (rented, owned)? 1 - Rented 2 - Owned 9 - Other (specify):

# Management

IM2 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 Standard Operating Procedures

IM4 a Are auto disable syringes available in this facility at the time of visit? 1.-Yes 2.-No

IM4 b Are sharp containers available in this facility at the time of visit? 1.-Yes 2.-No

IM4 c Are vaccine carrier(s) available in this facility at the time of visit? 1.-Yes 2.-No

IM4 d Set of icepacks for vaccine carriers available in this facility at the time of visit? 1.-Yes 2.-No

IM4 e 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

IM5 Does this facility has Ice Lined Refrigerator 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 – Ice Lined Refrigerator is out of order 4 – No Ice Lined refrigerator is available

IM6 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):

# Human Resource

EP4a Are vaccinators available in this EPI Facility? 1- Yes 2- No

EP4b If vaccinators are available, please share number of vaccinators currently providing services in this EPI facility? If there are no vaccinators type X

EP4c Are LHVs available in this EPI facility

EP4d If LHVs are available, please share number of LHVs currently providing services in this EPI facility? If there are no LHVs type X

EP5a What are the timings of this fixed health facility open? type number only “8” (24 hours format) Opens at: ………

EP5b What are the timings of this fixed health facility closed? type number only “15” (24 hours format) Closes at: …………

EP5c What are total working hours of the facility per day? Type a number only e.g.“8” Total working hours………..

# Environment & Facilities For The Patients

EN1 Is there any waiting area (separate for men and women patients) in the facility?

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1 – Yes, separate for men and women 2 – Yes, mixed waiting area for men and women 3 – No waiting area available

EN2 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

EN3 Is drinking water available for patients and their attendants in the facility? 1 – Yes 2 - No

EN4 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

EN5 Is the toilet facility usable for patients and their attendants in the facility? 1 – Yes, usable 2 – Not usable

EN6 How health facility/ EPI waste is being disposed from the site 1. Buried 2. Burnt 3. Burn and Buried 4. Dumped in health facility / garbage cane 5. Others

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Annex 4: Analysis of Profiling of Slums/Underserved Areas

Table 1: Number of Slums and Underserved

Cities Slums Underserved Sub Total



Lahore 356 637 993

Multan 216 104 320


Punjab Total 899 1265 2164

Islamabad 49 14 63

Quetta 281 34 315

Peshawar 550 22 572

Grand Total 1779 1335 3114

Table 2: 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

Islamabad 0 35 8 6 49

Quetta 25 174 58 24 281

Peshawar 235 265 42 8 550

Grand Total 425 1023 256 71 1779

Table 3: 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

Islamabad 49 21 28 49

Quetta 281 120 161 281

Peshawar 550 273 277 550

Grand Total 1779 1143 636 1779

Table 4: 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

Islamabad 273,840 105,800 379,640

Quetta 633,508 78,896 712,404

Peshawar 1,480,942 51,536 1,532,478

Grand Total 5,680,568 6,294,653 11,975,221

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Table 5a: 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

Islamabad 30,920 590 3,806 35,316

Quetta 79,890 6,464 4,798 91,152

Peshawar 153,038 39,725 11,734 204,497

Grand Total 760,422 128,538 24,252 913,212

Table 5b: Types of Residents in Underserved


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

Islamabad 12,205 620 0 12,825

Quetta 6,527 681 1,372 8,580

Peshawar 4,722 553 2 5,277

Grand Total 859,872 112,548 3,563 975,983

Table 5c: Types of Residents in Slums and Underserved (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

Islamabad 43,125 1,210 3,806 48,141

Quetta 86,417 7,145 6,170 99,732

Peshawar 157,760 40,278 11,736 209,774

Grand Total 1,620,294 241,086 27,815 1,889,195

Table 6: 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

Islamabad 4 10 0 0 14 0 4 0 0 4 18

Quetta 13 5 0 0 18 1 0 0 0 1 19

Peshawar 31 7 3 0 41 2 1 0 0 3 44

Grand Total 57 24 3 0 84 4 9 0 0 13 97

Table 7a: 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

Islamabad 2 7 0 9 40 49

Quetta 13 5 0 18 263 281

Peshawar 31 10 0 41 509 550

Grand Total 55 24 0 79 1700 1779

65

Table 7b: Underserved having Private and Public Health Facilities

Cities With Public





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


Punjab Total 1 4 0 5 1260 1265

Islamabad 0 3 0 3 11 14

Quetta 1 0 0 1 33 34

Peshawar 2 1 0 3 19 22

Grand Total 4 8 0 12 1323 1335

Table 7c: Slums and Underserved having Private and Public Health Facilities

Cities With Public





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

Islamabad 2 10 0 12 51 63

Quetta 14 5 0 19 296 315

Peshawar 33 8 3 44 528 572

Grand Total 59 29 3 91 3023 3114

Table 8a: Average Distance between Private Health Facilities and Slums

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



Lahore 0 0 356 356

Multan 0 0 216 216


Punjab Total 2 0 897 899

Islamabad 6 1 42 49

Quetta 3 0 278 281

Peshawar 6 0 544 550

Grand Total 17 1 1761 1779

Table 8b: Average Distance between Private Health Facilities and Underserved

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



Lahore 0 0 637 637

Multan 0 0 104 104



Islamabad 3 0 11 14

Quetta 0 0 34 34

Peshawar 1 0 21 22

Grand Total 8 0 1327 1335

Table 8c: Average Distance between Private Health Facilities and Slums/Underserved (Total)

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



Lahore 0 0 993 993

Multan 0 0 320 320



Islamabad 9 1 53 63

Quetta 3 0 312 315


Grand Total 25 1 3088 3114

66

Table 9: 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

Islamabad 3 46 0 14 3 60

Quetta 19 262 2 32 21 294

Peshawar 45 505 1 21 46 526

Grand Total 113 1666 98 1237 211 2903

Table 10a: 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


Lahore 15 0 0 0 341 356

Multan 8 0 0 1 207 216


Punjab Total 45 0 0 1 853 899

Islamabad 3 0 0 0 46 49

Quetta 17 2 0 0 262 281

Peshawar 45 0 0 0 505 550

Grand Total 110 2 0 1 1666 1779

Table 10b: 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


Punjab Total 95 0 0 0 1170 1265

Islamabad 0 0 0 0 14 14

Quetta 1 0 1 0 32 34

Peshawar 1 0 0 0 21 22

Grand Total 97 0 1 0 1237 1335

Table 10c: 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

Islamabad 3 0 0 0 60 63

Quetta 18 2 1 0 294 315

Peshawar 46 0 0 0 526 572

Grand Total 207 2 1 1 2903 3114

Table 11a: 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

Punjab Total 699 899

Islamabad 35 49

Quetta 101 281

Peshawar 529 550

Grand Total 1364 1779

67

Table 11b: 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


Islamabad 8 14

Quetta 12 34

Peshawar 22 22


Table 11c: 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


Islamabad 43 63

Quetta 113 315

Peshawar 551 572


Table 12a: Lady Health Worker in Slums

Cities LHWs Covered LHWs Uncovered Total Slums


Gujranwala 5 77 82

Lahore 222 134 356

Multan 70 146 216

Rawalpindi 33 43 76


Islamabad 17 32 49

Quetta 94 187 281

Peshawar 328 222 550

Grand Total 800 979 1779

Table 12b: Lady Health Worker in Underserved

Cities LHWs Covered LHWs Uncovered Total Underserved



Lahore 324 313 637

Multan 39 65 104

Rawalpindi 18 44 62


Islamabad 5 9 14

Quetta 11 23 34

Peshawar 7 15 22


Table 12c: Lady Health Worker in Slums/Underserved (Total)

Cities LHWs Covered LHWs Uncovered Total Slums/Underserved



Lahore 546 447 993

Multan 109 211 320



Islamabad 22 41 63

Quetta 105 210 315

Peshawar 335 237 572

Grand Total 1308 1806 3114

68

Table 13a: 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

Islamabad 49 31 18 14 10 4 41 22

Quetta 281 0 281 34 0 34 0 315

Peshawar 550 390 160 22 19 3 409 163

Grand Total 1779 1204 575 1335 1213 122 2417 697

Table 13b: Availability of 1038 Services

Cities

Slums # of

Underserved

Underserved Areas Slums/Underserved Areas

# of Slums

Slums With 1122

Slums Without

1122

Underserved With 1122

Underserved Without 1122

Slums/Underserved With 1122

Slums/Underserved Without 1122

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

Islamabad 49 5 44 14 4 10 9 54

Quetta 281 0 281 34 0 34 0 315

Peshawar 550 0 550 22 0 22 0 572

Grand Total 1779 21 1758 1335 53 1282 74 3040

Table 14: 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

Islamabad 22 27 7 7 29 34 63

Quetta 0 281 0 34 0 315 315

Peshawar 91 459 8 14 99 473 572

Grand Total 792 987 890 445 1682 1432 3114

69

Table 15a: 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

Islamabad 5,826 24,383 5,107 35,316

Quetta 59,833 11,021 20,298 91,152

Peshawar 46,264 97,066 61,167 204,497

Grand Total 182,365 372,542 358,305 913,212

Table 15b: Types of Housing Structure in Underserved


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

Islamabad 0 5,295 7,530 12,825

Quetta 0 7,978 602 8,580

Peshawar 0 4,548 729 5,277

Grand Total 0 841,618 134,375 975,993

Table 15c: Types of Housing Structures in Slums/Underserved (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

Islamabad 5,826 29,678 12,637 48,141

Quetta 59,833 18,999 20,900 99,732

Peshawar 46,264 101,614 61,896 209,774

Grand Total 182,365 1,214,160 492,680 1,889,205

Table 16a: Sources of Domestic Water in Slums

Cities Government Water

Supply Ground Water (Well, Hand Pump, Tube Well)

Acquire From Other Sources Of Water


Gujranwala 7 55 20

Lahore 111 118 127

Multan 40 158 18

Rawalpindi 22 38 16


Islamabad 12 31 6

Quetta 35 74 172

Peshawar 64 477 9


Table 16b: Sources of Domestic Water in Underserved

Cities Government Water Supply Ground Water (Well, Hand

Pump, Tube Well) Acquire From Other Sources Of Water


Gujranwala 23 64 78

Lahore 276 261 100

Multan 28 46 30

Rawalpindi 35 12 15


Islamabad 5 5 4

Quetta 12 4 18

Peshawar 2 20 0


70

Table 16c: 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



Lahore 387 379 227

Multan 68 204 48

Rawalpindi 57 50 31


Islamabad 17 35 11

Quetta 47 78 190

Peshawar 66 497 9


Table 17a : 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

Islamabad 7 3 0 0 2 37 49

Quetta 34 0 0 1 0 246 281

Peshawar 31 22 8 0 3 486 550

Grand Total 186 106 15 7 6 1459 1779

Table 17b: 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

Islamabad 3 0 0 0 2 9 14

Quetta 12 0 0 0 0 22 34

Peshawar 1 1 0 0 0 20 22

Grand Total 170 189 39 46 23 868 1335

Table 17c: 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

Islamabad 10 3 0 0 4 46 63

Quetta 46 0 0 1 0 268 315

Peshawar 32 23 8 0 3 506 572

Grand Total 356 295 54 53 29 2327 3114

71

Table 18a-: 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

Islamabad 34,173 1,143 35,316

Quetta 87,028 4,124 91,152

Peshawar 196,634 4,374 201,008

Grand Total 891,680 18,043 909,723

Table 18b: Availability of Household Toilet in Underserved


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

Islamabad 12,825 - 12,825

Quetta 8,025 555 8,580

Peshawar 5,247 30 5,277

Grand Total 967,370 8,613 975,983

Table 18c: Availability of Household Toilet in Slums/Underserved


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

Islamabad 46,998 1,143 48,141

Quetta 95,053 4,679 99,732

Peshawar 201,881 4,404 206,285

Grand Total 1,859,050 26,656 1,885,706

Table 19a: 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

Islamabad 17,501 16,672 34,173

Quetta 10,377 76,651 87,028

Peshawar 76,581 120,053 196,634

Grand Total 432,262 459,418 891,680

Table 19b: Type of Household Toilet in Underserved


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

Islamabad 6,222 6,603 12,825

Quetta 1,680 6,345 8,025

Peshawar 1,100 4,147 5,247

Grand Total 483,689 483,681 967,370

72

Table 19c : Type of Household Toilet in Slums/Underserved (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

Islamabad 23,723 23,275 46,998

Quetta 12,057 82,996 95,053

Peshawar 77,681 124,200 201,881

Grand Total 915,951 943,099 1,859,050

Table 20a: Average # of People using Toilet

Cities Average # of People Using Toilet

Faisalabad 6

Gujranwala 5

Lahore 6

Multan 7

Rawalpindi 7

Punjab Total 6

Islamabad 8

Quetta 9

Peshawar 9

Grand Total 8

Table 20b: Average # of People using Toilet in Underserved


Faisalabad 6

Gujranwala 7

Lahore 7

Multan 7

Rawalpindi 8

Punjab Total 7

Islamabad 5

Quetta 10

Peshawar 11

Grand Total 8

Table 20c: Average # of People using Toilet in Slums and Underserved Areas (Total)


Faisalabad 6

Gujranwala 6

Lahore 7

Multan 7

Rawalpindi 7

Punjab Total 7

Islamabad 7

Quetta 9

Peshawar 10

Grand Total 8

Table 21a: 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


Lahore 0 0 43 313 356

Multan 1 2 6 207 216


Punjab Total 1 4 85 809 899


Quetta 1 2 26 252 281

Peshawar 0 0 66 484 550

Grand Total 4 6 190 1579 1779

73

Table 21b: Modes of Defecation Without Toilet in Underserved




Lahore 0 0 18 619 637

Multan 0 0 2 102 104


Punjab Total 0 1 44 1220 1265


Quetta 0 0 0 34 34

Peshawar 0 0 1 21 22

Grand Total 0 1 45 1289 1335

Table 21c: Modes of Defecation Without Toilet in Slums/Underserved (Total)




Lahore 0 0 61 932 993

Multan 1 2 8 309 320


Punjab Total 1 5 129 2029 2164


Quetta 1 2 26 286 315

Peshawar 0 0 67 505 572

Grand Total 4 7 235 2868 3114

Table 22a-: Condition of Drains in Slums

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



Lahore 94 142 120 356

Multan 55 122 39 216


Punjab Total 240 414 245 899


Quetta 38 131 112 281

Peshawar 177 350 23 550

Grand Total 469 911 399 1779

Table 22b: Condition of Drains in Underserved

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



Lahore 65 239 333 637

Multan 22 45 37 104


Punjab Total 214 576 475 1265

Islamabad 2 9 3 14

Quetta 11 18 5 34

Peshawar 8 13 1 22

Grand Total 235 616 484 1335

Table 22c: Condition of Drains in Slums and Underserved (Total)

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



Lahore 159 381 453 993

Multan 77 167 76 320


Punjab Total 454 990 720 2164


Quetta 49 149 117 315

Peshawar 185 363 24 572

Grand Total 704 1527 883 3114

74

Table 23a: Solid Waste Disposal Practices in Slums

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



Lahore 169 4 183 356

Multan 80 3 133 216




Quetta 15 6 260 281

Peshawar 164 56 330 550

Grand Total 526 80 1173 1779

*Note: The option of other includes burnt and buried

Table 23b: Solid Waste Disposal Practices in Underserved




Lahore 458 12 167 637

Multan 55 1 48 104


Punjab Total 716 43 506 1265

Islamabad 3 1 10 14

Quetta 8 0 26 34

Peshawar 7 4 11 22

Grand Total 734 48 553 1335

Table 23c: Solid Waste Disposal Practices in Slums and Underserved (Total)




Lahore 627 16 350 993

Multan 135 4 181 320


Punjab Total 1050 60 1054 2164


Quetta 23 6 286 315

Peshawar 171 60 341 572

Grand Total 1260 128 1726 3114

Table 24a: 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

Islamabad 33 16 49 10 4 14

Quetta 145 136 281 23 11 34

Peshawar 459 91 550 22 0 22

Grand Total 1293 486 1779 1029 306 1335

Table 24 b: Schools in Slums and Underserved (Total)

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



Lahore 794 199 993

Multan 258 62 320



Islamabad 43 20 63

Quetta 168 147 315

Peshawar 481 91 572


75

Table 25a: Types of Schools in Slums

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

Faisalabad 55 84 9 51 2 63


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

Islamabad 24 16 8 5 0 16

Quetta 109 73 8 75 0 136

Peshawar 335 333 21 295 0 91

Grand Total 894 888 73 586 3 498

Table 25b: Types of Schools in Underserved


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

Islamabad 6 9 2 0 0 4

Quetta 22 18 2 11 0 11

Peshawar 20 17 0 17 0 0

Grand Total 600 828 84 433 2 316

Table 25c: Types of Schools in Slums and Underserved Areas (Total)


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

Islamabad 30 25 10 5 0 20

Quetta 131 91 10 86 0 147

Peshawar 355 350 21 312 0 91

Grand Total 1494 1716 157 1019 5 810

Table 26a: 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


Lahore 276 0 0 0 80 356

Multan 171 0 1 0 44 216


Punjab Total 651 3 1 1 243 899

Islamabad 33 0 0 0 16 49

Quetta 119 21 5 0 136 281

Peshawar 439 7 13 0 91 550

Grand Total 1242 31 19 1 486 1779

Table 26b: 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


Punjab Total 958 12 0 4 291 1265

Islamabad 10 0 0 0 4 14

Quetta 22 1 0 0 11 34

Peshawar 22 0 0 0 0 22

Grand Total 1012 13 0 4 306 1335

76

Table 26c: 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

Islamabad 43 0 0 0 20 63

Quetta 141 22 5 0 147 315

Peshawar 461 7 13 0 91 572

Grand Total 2254 44 19 5 792 3114

Table 27: Availability of Working by CSOs

Cities Slums Underserved Areas Slum/Underserved Areas


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

Islamabad 14 35 1 13 15 48

Quetta 0 281 0 34 0 315

Peshawar 4 546 0 22 4 568

Grand Total 33 1746 46 1289 79 3035

Table 28a: Types of Services by CSOs in Slums

Types of Services Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total

Islamabad Quetta Peshawar

Education 1 0 2 0 1 4 4 0 3

Health 0 0 4 0 1 5 3 0 1

Human Rights 0 0 3 0 0 3 3 0 0

(Micro Loans) 1 0 1 0 0 2 2 0 0

Water 0 0 0 0 1 1 2 0 0

Areas with no charity organization

167 82 346 216 73 884 35 281 546

Total 169 82 356 216 76 899 49 281 550

Table 28b: Types of Services by CSOs in Underserved Areas

Types of Services Faisalabad Gujranwala Lahore Multan Rawalpi

ndi Punjab Total

Islamabad

Quetta Peshawar

Education 12 0 15 0 0 27 1 0 0

Health 0 1 6 1 1 9 0 0 0

Human Rights 0 1 6 0 0 7 0 0 0

Loans 0 0 1 0 0 1 0 0 0

Water 1 0 0 0 0 1 0 0 0

No CSO 284 163 609 103 61 1220 13 0 22

Grand Total 297 165 637 104 62 1265 14 0 22

Table 28c: 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 5 0 3

Health 1 1 10 1 2 14 3 0 1

Human Rights 0 1 9 0 1 10 3 0 0

Loans 1 0 2 0 0 3 2 0 0

Water 1 0 0 0 0 2 2 0 0

No CSO 453 245 955 319 134 2104 48 281 568

Grand Total 466 247 993 320 138 2164 63 281 572

77

Table 29: Presence of Informal Groups

Cities Slums Underserved Slum/Underserved (Total)


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

Islamabad 25 24 4 10 29 34

Quetta 42 239 2 32 44 271

Peshawar 150 400 10 12 160 412

Grand Total 566 1213 516 819 1082 2032

Table 30a: 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 0 0 1

Jirga/Punchaiyat 0 1 3 1 4 9 1 16 17

Masjid/Church Committee 34 15 43 37 27 156 18 23 77

School Committee 0 0 1 4 0 5 0 0 3

Unregistered Community-Based Organization

5 0 1 12 6 24 4 3 48

Zakat Committee 12 5 28 20 6 71 2 0 4

No Informal Groups or Committees

113 56 218 156 33 581 24 239 400

Total 169 82 356 216 76 899 49 281 550

Table 30b: Types of Informal Groups in Underserved Areas

Types of Informal Groups

Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total




Masjid/ChurchCommittee 76 26 87 24 34 247 0 2 4



0 0 75 1 0 76 0 0 2

Zakat Committee 39 8 92 8 4 151 0 0 0


180 129 362 71 23 765 10 32 12

Grand Total 297 165 637 104 62 1265 14 34 22

Table 30c: Types of Informal Groups in Slums/Underserved Areas

Types of Informal Groups

Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total Islamabad Quetta Peshawar



Masjid/Church Committee

110 41 130 61 61 403 18 25 81



5 0 76 13 6 100 4 3 50

Zakat Committee 51 13 120 28 10 222 2 0 4


293 185 580 227 56 1346 34 271 412

Grand Total 466 247 993 320 138 2164 63 315 572

78

Table 31: Availability of Welfare Scheme by Government

Cities

Slums Underserved Areas Slums/Underserved

Total Slums

Covered Uncovered Total

Underserved Covered Uncovered

Total slums/Underserved

Covered Uncover

ed

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

Islamabad 49 21 28 14 4 10 63 25 38

Quetta 281 34 247 34 0 34 315 34 281

Peshawar 550 299 251 22 9 13 572 308 264

Grand Total 1779 704 1075 1335 808 527 3114 1512 1602

Table 32: 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

Islamabad

Slum 0 21 1 20 20 1 0 21 0 21

Underserved 1 3 1 3 2 0 0 4 0 4

Total 1 24 2 23 22 1 0 25 0 25

Quetta

Slum 0 2 0 2 32 2 2 0 0 2

Underserved 0 0 0 0 0 0 0 0 0 0

Total 0 2 0 2 32 2 2 0 0 2

Peshawar

Slum 5 294 38 261 250 13 6 293 0 299

Underserved 0 9 0 9 9 0 0 9 0 9

Total 5 303 38 270 259 13 6 302 0 308

Grand Total

Slum 48 323 99 291 542 25 14 322 1 335

Underserved 107 29 122 35 559 27 13 33 7 42

Total 155 352 221 326 1101 52 27 355 8 377

79

Annex 5: Analysis of Health Resources of Union Councils

Table 1: 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

Islamabad

Town Total UCs

NA 26

Peshawar

Town Total UCs

Town 1 25

Town 2 25

Town 3 26

Town 4 21

Total 97

Quetta

Town Total UCs

Chiltan 24

Zarghoon 26

Total 50

Grand Total 626

80

Table 1b: Status of Slums/Underserved in Union Councils

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


Gujranwala 58 6 64

Lahore 127 39 166

Multan 36 14 50

Rawalpindi 44 16 60

Islamabad 20 6 26

Peshawar 85 12 97

Quetta 22 28 50

Total 478 148 626

Table 2: 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

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

Islamabad

26 1529887

Peshawar

Town 1 25 767029

Town 2 25 1185663

Town 3 26 982311

Town 4 21 941093

Total 97 3876096

Quetta

Chiltan 24 1145777

Zarghoon 26 1301752

Total 50 2447529

81

Table 3: 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

Islamabad 1,529,887

Peshawar 3,876,096

Quetta 2,447,529

Grand Total 22,214,607

Table 4: Number of Health Facilities in UCs

Cities Health Facilties in Total UCs

Faisalabad 52

Gujranwala 29

Lahore 217

Multan 45

Rawalpindi 32

Islamabad 30

Peshawar 110

Quetta 63

Grand Total 578

Table 4a: UCs with/ without Health Facilities

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


Gujranwala 19 45 64

Lahore 160 6 166

Multan 34 16 50

Rawalpindi 28 32 60

Islamabad 17 9 26

Peshawar 80 17 97

Quetta 40 10 50


Table 5: Number of EPI Facilities

Cities Public EPI Facilities

Faisalabad 67

Gujranwala 18

Lahore 220

Multan 45

Rawalpindi 29

Islamabad 24

Peshawar 120

Quetta 69

Grand Total 592

Table 6: UCs with/ without EPI Facilities

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


Gujranwala 18 46 64

Lahore 165 1 166

Multan 34 16 50

Rawalpindi 29 31 60

Islamabad 18 8 26

Peshawar 94 3 97

Quetta 41 9 50


82

Table 7 : 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

Islamabad 24 0 24

Peshawar 111 9 120

Quetta 67 2 69


Table 8: 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

Islamabad 16 26

Peshawar 97 97

Quetta 50 50

Grand Total 616 626

Table 9a Nutrition Services

Cities Available in UCs Not Available in UCs Total


Gujranwala 19 45 64

Lahore 166 0 166

Multan 34 16 50

Rawalpindi 28 32 60

Islamabad 13 13 26

Peshawar 64 33 97

Quetta 9 41 50


Table 9b: Types of Nutrition Services in UCs

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



Lahore 12 0 22 144 0

Multan 34 0 0 0 16



Peshawar 0 0 2 64 33

Quetta 1 9 9 9 41

Grand Total 162 9 33 263 230

Table 10: 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

Islamabad 24 41

Peshawar 120 246

Quetta 69 120

Grand Total 592 931

83

Table 11: Number of UCs Covered by LHWs

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



Lahore 163 3 166 1335

Multan 42 8 50 265



Peshawar 64 33 97 1160

Quetta 31 19 50 516

Grand Total 467 159 626 3793

Table 12: Availability of Dengue Workers

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


Gujranwala 64 0 64

Lahore 166 0 166

Multan 50 0 50

Rawalpindi 60 0 60

Islamabad NA NA NA

Peshawar 97 0 97

Quetta 0 50 50


84

Annex 6: Analysis of Results of EPI Facility Assessment Table 1: 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

Islamabad

NA 26 21 24

Quetta

Chiltan 24 11 29

Zarghoon 26 11 25

Total 50 22 54

Peshawar

Town 1 25 23 28

Town 2 25 25 29

Town 3 26 21 36

Town 4 3 3 23

Total 79 72 116

Table 2: 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 – Punjab 199 23 228

Islamabad 19 5 24

Quetta 50 4 54

Peshawar 91 25 116


Note: 2 EPI Centres are donated by Peshawar University & Family Medical Care Centre

85

Table 3 Types of EPI Facilities

City Government Private Charity Total



Lahore 120 7 0 127

Multan 30 0 0 30


Sub total - Punjab 221 7 0 228

Islamabad 19 5 0 24

Quetta 52 0 2 54



Note: There is 1 EPI Centre Other than mentioned variables

Table 4: 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

Sub total - Punjab 4 224 228

Islamabad 6 18 24

Quetta 37 17 54

Peshawar 11 105 116


Table 5: 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


Islamabad 4 20 24

Quetta 10 44 54

Peshawar 52 64 116


Table 6: Availability of LHVs in EPI Facilities

City Available Not Available Total Total # of LHVs



Lahore 72 55 127 81

Multan 18 12 30 21




Quetta 32 22 54 45

Peshawar 74 42 116 143

Grand Total 259 163 422 377

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 7: Availability of Vaccinators in EPI Facilities

City Available Not Available Total Total # of Vaccinators



Lahore 127 0 127 225

Multan 30 0 30 31




Quetta 54 0 54 99

Peshawar 116 0 116 264


86

Table 8: Vaccine Supplies

Cities Availability of Types of Vaccine Supplies

Auto Disable Syringes Safety Boxes/ Sharp Containers Vaccine Carrier (s) Icepacks



Lahore 127 127 124 125

Multan 30 30 30 27




Quetta 54 54 53 50

Peshawar 105 112 115 114

Grand Total 405 418 415 409

Table 9: Supply of Vaccines

City Infrequent Shortage Frequent Shortage No Shortage Total



Lahore 0 0 127 127

Multan 0 0 30 30



Islamabad 0 0 24 24

Quetta 16 3 35 54



Table 10: Availability of Ice Lined Refrigerators

City Available Functional Available Non-Functional Not Available Total



Lahore 127 0 0 127

Multan 30 0 0 30



Islamabad 24 0 0 24

Quetta 52 2 0 54



Table 11: 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


Islamabad 13 11 24

Quetta 28 26 54

Peshawar 60 56 116


Table 12: 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


Islamabad 20 4 24

Quetta 34 20 54

Peshawar 73 43 116


Note: 12 EPI Facilities having no waiting areas

87

Table 13: 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


Islamabad 19 5 24

Quetta 28 26 54

Peshawar 87 29 116


Table 14: Availability of Toilets

City Gender Segregated

Available Gender Mixed Available Not Available Total


Gujranwala 3 8 7 18

Lahore 50 32 45 127

Multan 15 5 10 30

Rawalpindi 9 2 8 19


Islamabad 17 5 2 24

Quetta 30 10 14 54

Peshawar 45 47 24 116

Grand Total 180 132 110 422

Table 15: Usability of Toilet

Cities Useable Not Useable Toilet Not Available Total


Gujranwala 8 3 7 18

Lahore 72 10 45 127

Multan 14 6 10 30



Islamabad 20 2 2 24

Quetta 33 7 14 54

Peshawar 61 31 24 116

Grand Total 251 61 110 422

Table 16: 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


Islamabad 24 0 24

Quetta 54 0 54

Peshawar 116 0 116


s

Report of Profiles of Slums/Underserved Areas of - UNICEF

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