BACKGROUND Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme's performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme's insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities. METHODS We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO's six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes. RESULTS The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines. CONCLUSIONS The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals.

中文翻译：

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系统内系统：巴基斯坦扩大免疫规划的挑战和机遇。

背景技术巴基斯坦是世界上婴儿和儿童死亡率最高的国家之一，其中一半是由于疫苗可预防的疾病而发生的。该国于1978年开始实施扩大免疫计划（EPI）。但是，由于免疫率一直很低，而且按时接种率不理想，该计划的表现经常受到质疑。我们探讨了该计划在更大的治理体系中的结构和实施安排以及随之而来的挑战和机遇的见解。方法我们进行了定性的案例研究，包括对来自疫苗接种政策和计划实施各个层面的34位有针对性地选择的关键信息提供者进行的半结构化，深度访谈。访谈围绕世卫组织卫生系统的六个基本组成部分进行，它们与EPI对应者以及外部生态因素的相互作用。记录访谈内容并分析内容以发现紧急主题。结果EPI在为儿童提供常规免疫（RI）方面面临着若干挑战，包括不清楚是通过固定中心还是通过流动医疗队提供疫苗，各级人力资源匮乏，缺乏准确的人口数据，现场后勤问题，缺少针对EPI的单独预算项目，对脊髓灰质炎的全球压力，对政策预防的重视程度较低，基于社区的活动的安全风险以及社区对疫苗的误解。结论大多数挑战的支点在于，EPI服务交付与更广泛的卫生系统的各个组成部分相互作用。根除脊髓灰质炎的活动对RI产生了影响。来自国家和全球环境的社会政治问题也影响了该系统。这些因素的相互作用给有效实施RI带来了挑战，同时也带来了改进的机会。需要地方，国家和全球利益攸关方共同努力，以改善巴基斯坦儿童的免疫状况，全球卫生安全和可持续发展目标。