Report of Profiles of Slums/Underserved Areas of 08

Home , Bani Gala, Gujranwala, List of slums

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

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 Water, Sanitation and Hygiene WCBA Women of Child Bearing Age WHO World Health Organization WMC Waste Management Company

Executive Summary

8 largest cities including 05 cities of Punjab, one city of Khyber Pakhtunkhwa (Peshawar), one city of Balochistan Box 1: Major Inequities (Quetta) and Federal Capital Islamabad house 3114 Health Facilities  93% slums/underserved areas have slums/underserved areas. These slums/underserved areas difficult access to health and EPI facilities. are located in 76% of the total 626 UCs. Approximately 11.9  58% slums/underserved areas are not Million people reside in slums/underserved areas. 86% covered by LHWs. inhabitants of such areas are permanent settlers with the Infrastructure remaining 13% are temporarily displaced and 1% belong to  59% houses of slums are Kacha (un- other nationalities. cemented) or Kacha-Pacca (mixed structures);  36% slums are not registered. 36% slums are found to be unregistered and hence lacked WASH Facilities access to basic amenities such as adequate water supply  75% slums/underserved areas do not and sanitation systems as well as fully functional health have access to Government water supply system. systems. The housing conditions in such vulnerable areas  77% slums/underserved areas either do are very poor with the residents living in abysmal and not have drains or have choked and filthy dilapidated housing structures. Around 36% of the housing drains. structures present in slums are Kacha or Kacha-Pacca Education Facilities (mixed).  25% slums/underserved areas do not have schools. Social Welfare From the 99% houses having toilets, 51% have  51% slums/underserved areas do not traditional/open pit toilets. On an average, 8 people use a have access to any kind of Public welfare single toilet facility. 28% slums/underserved areas do not schemes 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.

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.

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. Figure 1: Continent wise Slum Population in 2014 According to a study conducted on “Size distributions of slums across the globe”, around 900 55.2 million people reside in the slum areas worldwide, a number which is expected to double by 2030 27.4 30.7 (Friesen, Taubenbock & Wurm, 2019). These 20.5 24.7 25.2 slums are mainly concentrated in the cities of the 11.1 Global South; where the world’s largest slum regions include Khayeltisha Cape Town in South Northern Latin Western Eastern Southern Southern Sub Africa; Kibera, Nairobi in Kenya; Dharavi, Mumbai in Africa America & Asia Asia East Asia Asia Saharan the Africa India; Orangi Town Karachi in Pakistan; Neza- Caribbean 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. Figure 2: Slums Population in 1990 & 2014 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 % of Slums Population 1990 Nigeria, slums was drastically higher for all the four countries 77% when compared to the year 2014 (Ritchie & Roser, India, 55% 2018)7. India decreased its slum population the China, Nigeria, most by 31% in the last 24 years. However, the Brazil, 44% 37% 50% number of slums present in India and other countries China, is still significant and their presence cannot be Brazil, India, 24% 22% 25% ignored. Source: OWID based on World Bank, World Development Indicators –

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

The comparison of these countries with Figure 3: Comparison of Slum Population in 1990s & 2014 Pakistan reveals that, Pakistan lists much lower in the number of urban slum Population in Millions in 2014 settlements. However, when compared on Population in Millions in 1990 the parameter of population growth between 1990 and 2014, it has been discovered that

Pakistan has shown an increase in 187.06 population growth for slums from nearly 16.79 million in 1990 to around 32.34 million 100.5 in 2014 (Our World in Data, 2014). The conditions of slums in Pakistan in terms of 130.87 122.04 38.91 population growth, health and immunization 41.58 40.52 32.34 and social problems have been further 21.86 16.79 investigated from the secondary data China India Nigeria Brazil Pakistan 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 Table 1: Population in 8 Largest Cities Population estimations, the population of City Census-2017 Census-1998 9 Lahore 11,126,285 5,143,495 Pakistan will reach to 242 Million by 2025 . Faisalabad 3,203,846 2,008,861 According to the estimation of UN for 2014, Rawalpindi 2,098,231 1,409,768 Gujranwala 2,027,001 1,132,509 the slum population was 32 Million in urban Peshawar 1,970,042 982,816 10 areas of Pakistan . Currently, 36.9% of the Multan 1,871,843 1,197,384 total population of Pakistan makes up urban Islamabad 1,014,825 529,180 Quetta 1,001,205 565,137 population, which is expected to increase to Total 24,313,278 12,969,150 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

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.

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

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

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

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].

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.

 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.

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.”

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).

Figure 4: Key activities in the study

Compile Health & EPI Resources • Slums located • Gender in 100% Union • Public Health Analysis of Councils of Basic Facilities & EPI Facilities Each Largest i& Resources • Supplies and City Line in Union Vaccine ListedProfiling of Councils Assess Fixed EPI Slums/Underserve Facilities d Areas

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.

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 Residents of slums / underserved A. Questionnaire for Group Discussion underserved areas areas 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 District Health Officer, District EPI C. Questionnaire for District or Town data at union council levels Coordinator and District Supervisor Health Office Vaccination or their nominees

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.

Inclusion Criteria Exclusion Criteria A. Resident of either slum or underserved area which was to A. Not the resident of either slum or underserved area be profiled 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 C. No knowledge about the physical infrastructure and facilities of that particular area 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 1. Slums and Underserved Areas 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 1. Administrative Layout data 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.

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).

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 Legal Facilities Location Structure Status Category A More than 60 Mostly Mostly No solid/liquid waste Mostly under the bridge, near households Kacha/mud illegal management system No river, railway station and any made/Tented government water supply empty land within the city Category B Less than 60 Mostly Mostly No solid/liquid waste Surrounded by big houses households Kacha/mud Illegal management system No made/Tented government water supply Category C More than 60 Mostly Mostly Mostly garbage Mostly upgraded from slums or households Pacca/ legal management system and housing societies or extension Plastered drains exist of towns Category D More than 100 Mostly un- Mostly No solid/liquid waste Originally rural area but households plastered legal management system No gradually became part of the government water supply 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 Figure 5: Study team composition A three-tiered teams were engaged in in- depth profiling of slums and underserved Data areas, assessment of fixed EPI facilities in Collectors slums and underserved areas and 1. Team Leader Supervisors Data Entry compilation of health and EPI resources Operators data of union councils. 2. Data Validation Data Assistant Team The first tier of team comprised of a team leader, survey supervisors and data 3. Report Writer Data Analyst collectors. The team leader provided overall Graphic guidelines and end-to-end management of Designer 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).

Chapter 3 Profile of Slums/Underserved Areas

11.9 98% Million Slums/ Underserved People live in Slums/ Areas Underserved Areas Report No Access to Public Health Facilities

93% 29% Slums/ Underserved 58% Slums/ Underserved Areas Report No Slums/ Underserved Areas Report No Access to EPI Areas are not covered Coverage for Facilities by LHWs Outreach

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, Figure 6: % UCs with Slums/Underserved which are further divided into 626 UCs. 76% Union Councils house 3114 slums/underserved areas. These 76% Total 76% UCs house a greater number of slums GJR 91% (1779) compared to underserved areas PWR 88% (1335). Highest percentage of spread of LHR 77% slums/underserved areas across UCs is MTN 77% found in Gujranwala (91%). The lowest IBD 77% spread of slums/underserved areas across FSD 76% UCs is found in Quetta (44%). Around 70% UCs house slums/underserved areas RWP 73% in remaining cities. QTA 44%

3.1.2 Slums/Underserved Areas

Overall, there are 1779 slums and 1335 Table 5: Number of Slums/Underserved underserved areas located in 478 UCs. The Cities Slums Underserved Total highest number of slums is found in Faisalabad 169 297 466 Gujranwala 82 165 247 Peshawar (550) followed by Lahore (356) Lahore 356 637 993 and Quetta (281). While the number of Multan 216 104 320 Rawalpindi 76 62 138 underserved areas is highest in Lahore Islamabad 49 14 63 (637) and Faisalabad (297). The lowest Quetta 281 34 315 number of slums/underserved areas is Peshawar 550 22 572 Total 1779 1335 3114 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).

Figure 7: Timelines of Existence of Slums 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 1991 onwards 1951-1990 Before 1950 during 1950 to 1990 (58%) at a similar pace 18% 58% Total 24% for all 08 cities. The lowest growth during 9% PWR 48% 1950s to 1990s is found in Peshawar (48%). 43% 29% 62% The highest growth of slums before 1990s is QTA 9% 28% 72% found in Islamabad (72%) and Faisalabad IBD 0% 25% (65%). The growth of slums during 1950s to 65% FSD 10% 16% 1990s could be because of industrial growth 63% LHR 21% or decline of agricultural profits. The lowest 19% RWP 61% growth of slums after 1991 is seen in 20% 25% MTN 60% Peshawar where percentage of slum growth 15% 20% 59% drops from 48% to only 9%. GJR 21%

3.1.4 Legal Status 36% slums are not registered72 with highest Figure 8: % of Unregistered Slums unregistered slums in Quetta (57%), Islamabad (57%) and Peshawar (50%). In 57% 57% Punjab, the percentage varies across cities, 50% as Gujranwala (43%) has the highest 43% percentage of unregistered slums. whereas, 36% they are lowest for Faisalabad (11%), 24% Multan (17%) and Lahore (18%). The 17% 18% registration status of slums determines the 11% eligibility to have resource allocation for having public services such as health, education, water and sanitation etc. The FSD MTN LHR RWP GJR PWR IBD QTA Total 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

3.2 Demography 3.2.1 Population There are approximately 11.9 Million Table 6: Approximate Population of Slums/Underserved Cities Slums Underserved Total people living in slums/underserved Faisalabad 459,327 881,049 1,340,376 areas, which is about 49% of the total Gujranwala 289,610 1,179,940 1,469,550 73 Lahore 1,519,936 3,130, 318 4, 650, 254 population (24.3 Million) of the 8 Multan 491,250 432,270 923,520 cities surveyed. The higher population Rawalpindi 532,155 434,844 966,999 share resides in underserved areas as Islamabad 273,840 105,800 379,640 Quetta 633,508 78,896 712,404 compared to slums. The largest Peshawar 1,480,942 51,536 1,532,478 population size in slums/underserved Total 5,680,568 6,294,653 11,975,221 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 Table 7: Approximate Population of Children 0-11 Months 74 Cities Slums Underserved Total children aged 0-11 months residing Faisalabad 14,790 28,370 43,160 in slums/underserved areas is 0.38 Gujranwala 9,325 37,994 47,319 Lahore 48, 942 100,796 149,738 Million. City wise comparison reflects Multan 15,818 13,919 29,737 highest number of target population Rawalpindi 17,135 14,002 31,137 resides in Lahore followed by Islamabad 8,818 3,407 12,224 Quetta 20,399 2,540 22,939 Peshawar. Lowest number of target Peshawar 47,686 1,659 49,346 population resides in Islamabad, Total 182,913 202,687 385,600 Quetta and Multan.

The population of children under 5 75 years of age residing in slums/underserved area is 2 Million. With the similar Table 8: Approximate Population Children Under 5 Years of Age trends, the highest number of children Cities Slums Underserved Total Faisalabad 78,086 149,778 227,864 under 5 years of age is found in Gujranwala 49,234 200,589 249,823 Lahore followed by Peshawar. The Lahore 258,389 532,154 790,543 lowest number of children under 5 Multan 83,513 73,486 156,999 Rawalpindi 90,466 73,923 164,389 years of age is found in Islamabad. Islamabad 46,553 17,986 64,539 Quetta 107,696 13,412 121,108 Peshawar 251,760 8,761 260,521 The approximate population of child Total 965,697 1,070,089 2,035,786 bearing age women76 residing in slums/underserved areas of 8 largest Table 9: Population of Child Bearing Age Women cities of Pakistan is 2.6 Million. Cities Slums Underserved Total Faisalabad 101,052 193,831 294,883 Slums/Underserved areas of Lahore Gujranwala 63,714 259,587 323,301 stand first with the highest Lahore 334,386 688,670 1,023,056 concentration of population of child Multan 108,075 950,99 203,174 Rawalpindi 117,074 956,66 212,740 bearing age women. Islamabad 60,245 23,276 83,521 Slums/Underserved areas of Quetta 139,372 17,357 156,729 Peshawar 325,807 11,338 337,145 Islamabad share merely 3% of the Total 1,249,725 1,384,824 2,634,549 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

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 Table 10: Permanent Settlers settlers. Highest proportion of permanent Cities Slum Underserved Total settlers is found in slums/underserved areas Faisalabad 81% 83% 82% Gujranwala 96% 91% 92% of Gujranwala (92%) and Islamabad (90%). Lahore 87% 89% 89% Lowest proportion of permanent settlers is Multan 87% 91% 89% found in Quetta (76%). Over 80% of Rawalpindi 76% 81% 78% Islamabad 88% 95% 90% residents of slums/underserved areas are Quetta 88% 76% 87% permanent in all other cities. Peshawar 75% 89% 75% Total 83% 88% 86% 3.2.2.b Temporary Displaced Overall 13% residents of slums/underserved Table 11: Temporary Displaced areas are temporarily displaced. Highest Cities Slum Underserved Total Faisalabad 19% 17% 18% proportion of temporary displaced is found in Gujranwala 4% 9% 8% Peshawar (19%), Rawalpindi (19%) and Lahore 13% 10% 11% Faisalabad (18%). Lowest proportion of Multan 12% 9% 11% Rawalpindi 20% 19% 19% temporary displaced is found in Islamabad Islamabad 2% 5% 3% (3%), Quetta (7%) and Gujranwala (8%). Quetta 7% 8% 7% Over 10% residents are found temporary Peshawar 19% 10% 19% Total 13% displaced in Lahore (11%) and Multan (11%). 14% 12%

3.2.2c Other Nationalities Overall 1% residents of slums/underserved Table 12: Residents Belonging to Other Nationalities areas belong to other Nationalities. Cities Slum Underserved Total Residents belonging to other Nationalities are Faisalabad 0% 0% 0% Gujranwala 0% 0% 0% found in five out of eight cities. Highest Lahore 0% 0% 0% concentration of residents belonging to other Multan 1% 1% 1% Nationalities are found in Islamabad (10%) Rawalpindi 3% 0% 2% followed by Peshawar (6%) and Quetta (5%). Islamabad 10% 0% 8% Quetta 5% 16% 6% A negligible percentage of residents Peshawar 6% 0% 6% belonging to other Nationalities are found in Total 3% 0% 1% 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 Table 13: UCs with/without Health Facilities Facilities. Intra-city comparison within UCs with Health UCs without Health Cities Punjab reveals the highest percentage Facilities Facilities Total of UCs lacking public health facilities Faisalabad 46% 54% 100% Gujranwala 30% 70% 100% being driven mainly from Gujranwala Lahore 96% 4% 100% where 70% UCs do not house such Multan 68% 32% 100% facilities followed by Faisalabad (54%) Rawalpindi 47% 53% 100% Islamabad 65% 35% 100% and Rawalpindi (53%). A large Quetta 80% 20% 100% percentage of UCs in Islamabad (35%) Peshawar 82% 18% 100% followed by Quetta (20%) and Total 69% 31% 100% 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.

3.3.2 EPI Facilities Overall, 26% Union Councils do not have Table 13: UCs with/without EPI Facilities UCs with EPI UCs without EPI Cities any EPI facilities. The percentage of UCs Facilities Facilities Total without EPI facilities is highest in Gujranwala Faisalabad 55% 45% 100% (72%) followed by Rawalpindi (52%), Gujranwala 28% 72% 100% Faisalabad (45%) and Multan (32%). 99% Lahore 99% 1% 100% Multan 68% 32% 100% UCs of Lahore have EPI facilities. It is Rawalpindi 48% 52% 100% interesting to note that only 7% Islamabad 69% 31% 100% slums/underserved areas report about the Quetta 82% 18% 100% Peshawar 97% 3% 100% presence of EPI facility within 2 km radius. Total 74% 26% 100% 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 Table 14: Availability of Outreach Vaccination Cities Slums Underserved Total provision of outreach vaccination services in Faisalabad 64% 64% 64% their areas. When non-provision of outreach Gujranwala 27% 33% 31% vaccination service is analyzed, the highest Lahore 83% 67% 73% Multan 93% 100% 95% percentage of slums/underserved areas of Rawalpindi 95% 90% 93% Gujranwala (69%), Quetta (64%) and Islamabad 71% 57% 68% Quetta 36% 35% 36% Faisalabad (36%) stands out. Whereas this Peshawar 96% 100% 96% percentage is comparatively lowest in Total 77% 65% 71% 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% Table 15: LHWs Uncovered Slums/Underserved Areas 77 Cities Slums Underserved Total slums/underserved areas. More Faisalabad 82% 76% 78% underserved areas are uncovered by LHWs Gujranwala 94% 81% 85% (62%) as compared to slums (55%). Majority Lahore 38% 49% 45% Multan 68% 63% 66% of the slums/underserved of Gujranwala Rawalpindi 57% 71% 63% (85%) and Faisalabad (78%) report that their Islamabad 65% 64% 65% Quetta 67% 68% 67% areas are uncovered by LHWs. The Peshawar 40% 68% 41% percentage of slums/underserved areas Total 55% 62% 58% uncovered for LHWs is low in Peshawar (41%) and Lahore (45%).

3.3.4b Dengue Workers Overall 36% slums/underserved areas do not Table 16: Unavailability of Dengue Workers Cities Slums Underserved Total have dengue workers present in them. 83% Faisalabad 57% 54% 55% slums/underserved areas of Peshawar are Gujranwala 0% 68% 45% without dengue workers; while in Faisalabad Lahore 24% 17% 20% 78 Multan 17% 7% 13% (55%), Islamabad 54% and Gujranwala Rawalpindi 0% 0% 0% (45%) slums/underserved areas do not have Islamabad 55% 50% 54% Quetta NA NA NA dengue workers in them. Although all slums/ Peshawar 83% 64% 83% underserved areas of Rawalpindi have Total 46% 31% 36% 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. .

3.3.5 Emergency Health Services On the whole, 14% slums/underserved areas Table 17: Unawareness about 1122 Service Cities Slums Underserved Total are unaware of 1122 services. High Faisalabad 8% 4% 6% percentage (35%) of residents of Gujranwala 0% 9% 6% slums/underserved areas of Islamabad is Lahore 28% 8% 15% Multan 1% 1% 1% unaware of 1122 service. Within the 5 cities of Rawalpindi 0% 0% 0% Punjab, a very negligible percentage of Islamabad 37% 29% 35% Quetta NA NA NA slums/underserved areas of Multan (1%), Peshawar 29% 14% 28% Faisalabad (6%) and Gujranwala (6%) report Total 20% 7% 14% 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 Table 18: Unawareness about 1038 Services Cities Slums Underserved Total stark contrast can be observed with respect to Faisalabad 96% 98% 97% unawareness of 1038 services where in Gujranwala 100% 99% 99% nearly all cities surveyed, the percentages are Lahore 97% 94% 95% Multan 100% 100% 100% close to, if not in actuality, a full 100%. Rawalpindi 100% 100% 100% Overall (97%) slums/underserved areas are Islamabad 90% 71% 86% Quetta NA NA NA unaware of 1038 service. No slum or Peshawar NA NA NA underserved area in Rawalpindi and Multan Total 98% 96% 97% 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 Table 19: Kacha/Tented Housing Structures Overall 20% houses in slums are found with Cities Slums Underserved Total Kacha/tented structures while none of the Faisalabad 9% 0% 3% housing structures in underserved areas are Gujranwala 15% 0% 3% Lahore 13% 0% 5% found with Kacha/tented structures. Highest Multan 9% 0% 5% percentage of Kacha/tented structures is Rawalpindi 15% 0% 8% Islamabad 17% 0% 12% found in Quetta (66%), followed by Quetta 66% 0% 60% Peshawar (23%) while the lowest proportion Peshawar 23% 0% 22% of Kacha/tented structures are found in Total 20% 0% 10% Faisalabad (9%) and Multan (9%).

3.4.1b Kacha-Pacca Table 20: Kacha-Pacca Housing Structures Overall 26% housing structures in Cities Slums Underserved Total Faisalabad 57% 15% 30% slums/underserved areas are found Kacha Gujranwala 38% 24% 27% Pacca. Greater percentage of slums (39%) Lahore 52% 5% 22% has Kacha-Pacca housing structures Multan 42% 21% 33% Rawalpindi 33% 25% 30% compared to underserved areas (14%). Islamabad 14% 59% 26% Highest percentage of Kacha Pacca Quetta 22% 7% 21% Peshawar 30% 14% 30% structures is found in slums/underserved Total 39% 14% 26% areas of Multan (33%), Faisalabad (30%), Rawalpindi (30%) and Peshawar (30%).

79 1122 service do not exist in Quetta City

3.4.1c Pacca Overall 64% houses in slums/underserved Table 21: Pacca Housing Structures Cities Slums Underserved Total areas are found with Pacca structures. Greater Faisalabad 34% 85% 67% percentage of housing structures of Gujranwala 47% 76% 70% underserved areas is Pacca (86%) compared to Lahore 35% 95% 74% Multan 49% 79% 61% slums (41%). The lowest percentage of Pacca Rawalpindi 52% 75% 62% housing structures is found in slums of Quetta Islamabad 69% 41% 62% Quetta 12% 93% 19% (12%). Over 70% housing structures of Peshawar 47% 86% 48% underserved areas of all cities have Pacca Total 41% 86% 64% 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 Table 22: Housing Structures without Toilets in slums (2%) is found without toilets Cities Slums Underserved Total compared to underserved areas (1%). Faisalabad 2% 1% 1% Gujranwala 1% 0% 1% Highest percentage of housing structures Lahore 2% 0% 1% in Quetta (5%) is found without toilets Multan 1% 6% 3% Rawalpindi 1% 0% 0% across eight cities. None of the housing Islamabad 3% 0% 2% structures are without toilets in Quetta 5% 6% 5% underserved areas of four cities. The Peshawar 2% 1% 2% Total 2% 1% 1% 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 Table 23: Open Pit/Traditional Toilets Cities Slums Underserved Total pit/traditional toilets. Housing structures of Faisalabad 45% 36% 39% almost an equal percentage of slums/ Gujranwala 36% 30% 32% underserved areas have open pit/traditional Lahore 37% 58% 51% Multan 48% 60% 53% toilets. Highest percentage of open Rawalpindi 55% 64% 59% pit/traditional toilets is found in Quetta (87%) Islamabad 49% 51% 50% Quetta 88% 79% 87% followed by Peshawar (62%). Over 50% toilets Peshawar 61% 79% 62% in slums/underserved areas of six cities are Total 52% 50% 51% open pit/traditional.

About half of the available toilets in slums/underserved areas are connected with the street drains. Highest percentage of toilets connected Table 24: Toilet with Connected Street Drains with street drains are found in Cities Slums Underserved Total Faisalabad 55% 64% 61% slums/underserved areas of Gujranwala (68%) Gujranwala 64% 70% 68% and Faisalabad (61%). Lowest percentage of Lahore 63% 42% 49% toilets connected with street drains are found in Multan 52% 40% 47% Rawalpindi 45% 36% 41% Quetta (13%). Less than 50% toilets connected Islamabad 51% 49% 50% with street drains are found in Peshawar (38%), Quetta 12% 21% 13% Peshawar 39% 21% 38% Rawalpindi (41%), Multan (47%) and Lahore Total 48% 50% 49% (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).

3.4.3 Domestic Water Overall, only 25% slums/underserved areas Table 25: Access to Government Water Supply have access to government water supply for Cities Slums Underserved Total Faisalabad 17% 30% 25% domestic use. Highest percentage of Gujranwala 9% 14% 12% slums/underserved areas of Rawalpindi (41%) Lahore 32% 43% 39% Multan 18% 27% 21% and Lahore (39%) has access to government Rawalpindi 28% 56% 41% water supply. A very low percentage of Islamabad 25% 36% 27% Quetta 12% 35% 15% slums/underserved areas of Peshawar (12%) Peshawar 12% 9% 12% and Gujranwala (12%) have access to Total 18% 35% 25% government water supply.

Overall almost half of the slums/underserved Table 26: Ground Water Cities Slums Underserved Total areas use ground water for domestic purposes. Faisalabad 74% 15% 36% When slums/underserved areas are compared Gujranwala 67% 39% 48% for the use of ground water, it is found that Lahore 33% 41% 38% Multan 73% 45% 64% majority of slums (60%) use ground water Rawalpindi 50% 20% 36% compared to underserved areas (34%). Highest Islamabad 63% 36% 56% Quetta 27% 12% 26% percentage of users of ground water is found in Peshawar 87% 91% 87% slums/underserved areas of Peshawar (87%) Total 60% 34% 49% 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 Table 27: Acquire from Other Sources 80 Cities Slums Underserved Total areas use other sources of water for domestic Faisalabad 9% 55% 38% purposes. Higher percentage of underserved Gujranwala 24% 47% 40% areas (31%) relies on other sources of water Lahore 35% 16% 22% Multan 8% 29% 15% compared to slums (22%). Highest percentage Rawalpindi 22% 25% 22% of underserved areas in Faisalabad (55%) and Islamabad 12% 28% 17% Quetta 61% 53% 59% Quetta (53%) rely on other sources of water for Peshawar 1% 0% 1% domestic purposes. Total 22% 31% 25%

3.4.4 Waste Management 3.4.4a For Liquid Waste Overall, 28% slums/underserved areas do not Table 28: No Drains Cities Slums Underserved Total have drains. Highest percentage of Faisalabad 27% 16% 20% slums/underserved areas in Lahore (46%) Gujranwala 37% 30% 32% followed by Quetta (37%), Islamabad (35%) and Lahore 34% 52% 46% Multan 18% 36% 24% Gujranwala (32%) are found without drains. Rawalpindi 14% 13% 14% Lowest percentage of slums/underserved areas Islamabad 39% 22% 35% Quetta 40% 15% 37% in Peshawar (4%) report about absence of Peshawar 4% 5% 4% drains in them. Total 22% 36% 28%

More than half of the slums/underserved areas Table 29: Choked/Filthy Drains Cities Slums Underserved Total have choked/filthy drains. Highest percentage Faisalabad 54% 57% 56% of slums/underserved area in Peshawar Gujranwala 46% 55% 52% (63%) followed by Faisalabad (56%), Multan Lahore 40% 38% 38% Multan 56% 43% 52% (52%) and Gujranwala (52%) has choked/filthy Rawalpindi 26% 50% 37% drains. Similarly a substantial percentage of Islamabad 33% 64% 40% Quetta 47% 53% 47% slums/underserved areas in Quetta (47%), Peshawar 64% 59% 63% Islamabad (40%) and Lahore (38%) have Total 51% 46% 49% choked/filthy drains.

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

Overall 23% slums/underserved areas have drains with running water. Highest percentage Table 30: Drains have Running Water Cities Slums Underserved Total of slums/underserved areas of Rawalpindi Faisalabad 19% 27% 24% (49%) followed by Peshawar (32%) is found Gujranwala 17% 15% 16% Lahore 26% 10% 16% drains with running water. Very small Multan 25% 21% 24% percentage of drains of slums/underserved Rawalpindi 59% 37% 49% Islamabad 28% 14% 25% areas of three cities namely Gujranwala (16%), Quetta 14% 32% 16% Lahore (16%) and Quetta (16%) are found Peshawar 32% 36% 32% drains with running water. Total 26% 18% 23%

3.4.4b For Solid Waste Overall 55% slums/underserved areas do not Table 31: Throw Solid Waste on Empty Plots/Streets Cities Slums Underserved Total have waste pick up facility provided by the Faisalabad 68% 52% 58% government hence majority of them throw their Gujranwala 82% 72% 75% waste on empty plots or in streets. Higher Lahore 52% 26% 35% Multan 62% 46% 57% percentage of slums (66%) compared to Rawalpindi 66% 31% 50% underserved areas (41%) throw waste on empty Islamabad 71% 71% 72% Quetta 93% 76% 91% plots or in streets. City wise comparison found Peshawar 60% 50% 60% that the highest percentage of Total 66% 41% 55% 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%) Table 32: WMC Vehicle Picks Up Solid Waste compared to slums (30%) have waste pick up Cities Slums Underserved Total facility by the government. City wise Faisalabad 28% 43% 38% Gujranwala 13% 20% 18% comparison found that the highest percentage Lahore 47% 72% 63% of slums/underserved areas in Lahore (63%), Multan 37% 53% 42% Rawalpindi (49%) and Multan (42%) has waste Rawalpindi 34% 66% 49% Islamabad 27% 22% 25% pick up facility by the government. Lowest Quetta 5% 24% 7% percentage of slums/underserved areas in Peshawar 30% 32% 30% Quetta (7%), Gujranwala (18%) and Islamabad Total 30% 55% 40% 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 Table 33: Self System for Solid Waste Management the waste. City wise comparison reflects that Cities Slums Underserved Total Faisalabad 4% 5% 4% 10% slums/underserved areas of Peshawar Gujranwala 5% 8% 7% followed by Gujranwala (7%) and Faisalabad Lahore 1% 2% 2% Multan 1% 1% 1% (4%) practice self system. Lowest percentage Rawalpindi 0% 3% 1% of slums/underserved areas with self-system is Islamabad 2% 7% 3% found in Rawalpindi (1%) and Multan (1%). Quetta 2% 0% 2% Peshawar 10% 18% 10% Total 4% 4% 4% 3.5 Social Welfare

3.5.1 Schools Table 34: Slums/Underserved without Schools Cities Slums Underserved Total Overall, 25% slums/underserved areas are Faisalabad 37% 26% 30% without schools. Highest percentage of Gujranwala 30% 41% 37% absences of schools is found in Lahore 22% 19% 20% Multan 20% 17% 19% slums/underserved areas of Quetta (47%). Rawalpindi 41% 18% 30% Lowest percentage of absence of schools is Islamabad 33% 29% 32% found in slums/underserved areas are Lahore Quetta 48% 32% 47% Peshawar 17% 0% 16% (20%), Multan (19%) and Peshawar (16%). Total 27% 23% 25%

Overall, 64% slums/underserved areas have government schools. Higher percentage of government schools is found in slums/underserved of Quetta (78%), Multan Table 35: Presence of Government Schools Cities Slums Underserved Total (78%), Peshawar (74%) and Islamabad (70%). Faisalabad 52% 51% 51% About half of the slums/ underserved areas of Gujranwala 56% 54% 55% Gujranwala (55%) and Faisalabad (51%) report Lahore 68% 57% 60% Multan 81% 71% 78% presence of Government schools. A higher Rawalpindi 60% 63% 61% percentage of slums (69%) have presence of Islamabad 73% 60% 70% Quetta 75% 96% 78% Government schools compare to underserved Peshawar 73% 91% 74% areas (58%). Highest percentage of Total 69% 58% 64% 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 Table 36: Presence of CSOs Cities Slums Underserved Total reflects that slums/underserved areas of Quetta Faisalabad 1% 4% 3% and Multan have no presence of CSOs. CSOs Gujranwala 0% 1% 1% are found in highest percentage of Lahore 3% 4% 4% Multan 0% 1% 0% slums/underserved areas of Islamabad (31%). Rawalpindi 4% 2% 3% A negligible percentage of slums/underserved Islamabad 29% 7% 31% Quetta 0% 0% 0% areas of Lahore (4%), Rawalpindi (3%), Peshawar 1% 0% 1% Faisalabad (3%), Peshawar (1%) and Total 2% 3% 3% 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 Table 37: Informal Groups have informal groups. Highest percentage Cities Slums Underserved Total Faisalabad 33% 39% 37% of informal groups is found in Gujranwala 32% 22% 23% slums/underserved areas of Rawalpindi Lahore 39% 43% 42% Multan 40% 32% 37% (59%) and Islamabad (46%) while lowest Rawalpindi 57% 63% 59% percentage of informal groups is found in Islamabad 51% 29% 46% slums of Quetta (14%). The percentage Quetta 15% 6% 14% Peshawar 27% 45% 28% of presence of informal groups is higher Total 32% 39% 35% 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%).

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 Table 38: Availability of Public Welfare Schemes Cities Slums Underserved Total Overall 49% slums/underserved areas have Faisalabad 33% 46% 41% public welfare schemes. The highest Gujranwala 49% 59% 55% percentage of public welfare schemes is found Lahore 41% 80% 66% Multan 37% 27% 34% in slums/underserved areas of Lahore (66%), Rawalpindi 38% 35% 37% Gujranwala (55%) and Peshawar (54%). The Islamabad 43% 29% 40% Quetta 12% 0% 11% lowest percentage of public welfare schemes is Peshawar 54% 41% 54% found in Quetta (11%). Total 40% 61% 49%

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.

Chapter 4 Health Resources in Union Councils

76% 31% 478 UCs have 196 UCs are Without either Slum or Public Health Underserved Areas Facilities

26% 37% 25% 165 UCs are Without 230 UCs are Without 159 UCs are not EPI Facilities Nutrition Services Covered by Lady Health Workers

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 Table 39: UCs with/without Slums/Underserved UCs With Slums & distributed into 31 towns and 626 UCs. 76% of Cities Towns Total UCs Underserved 626 UCs house slums/underserved areas. Faisalabad 4 113 86 76% Highest spread of slums/underserved areas Gujranwala 4 64 58 91% Lahore 10 166 127 77% across UCs is found in Gujranwala (91%) and Multan 4 50 36 72% lowest spread of slums/underserved areas Rawalpindi 3 60 44 73% across UCs is found in Quetta (44%). More than Islamabad NA 26 20 77% Quetta 2 50 22 44% 70% of UCs of seven cities house Peshawar 4 97 85 88% slums/underserved areas. Total 31 626 478 76%

Although, the spread of slums/ underserved Table 40: Population of Slums/Underserved UCs With Slums/ Population of total areas are higher in some cities but their Cities Underserved Slums/Underserved population sizes are lower. For example 91% # % Faisalabad 86 76% 1,340,376 UCs of Gujranwala (1.4 Million) house slums/ Gujranwala 58 91% 1,469,550 underserved areas but their population size is Lahore 127 77% 4, 650, 254 lower than Peshawar (1.5 Million) where 88% Multan 36 72% 923,520 Rawalpindi 44 73% 966,999 UCs house slums/ underserved areas. Similarly, Islamabad 20 77% 379,640 77% UCs of Islamabad house slums/ Quetta 22 44% 712,404 Peshawar 85 88% 1,532,478 underserved areas but their population size is Total 478 76% 11,975,221 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 Table 41: UCs with/without Health Facilities # of UCs with Health # of UCs without health facilities. Within 05 cities of Punjab, the Cities Facilities Health Facilities city that contributes the most to this percentage Faisalabad 52 46% 61 54% is Gujranwala with 70% of its UCs not having Gujranwala 19 30% 45 70% such facilities. This is followed by 54% UCs not Lahore 160 96% 6 4% Multan 34 68% 16 32% having public health facilities in Faisalabad and Rawalpindi 28 47% 32 53% 53% of Rawalpindi. On the other end of the Islamabad 17 65% 9 35% Quetta 40 80% 10 20% spectrum lies Lahore, having only 04% of UCs Peshawar 80 82% 17 18% devoid of any such facilities. About less than a Total 17 65% 196 31% 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 Table 42: Health Facilities Vs. UCs # of Public Health Facilities in Cities Total UCs located in 430/626 UCs. The highest number of Total UCs such facilities is located in Lahore (217) followed Faisalabad 113 52 Gujranwala 64 29 by Peshawar (110) and Quetta (63). Gujranwala Lahore 166 217 (29) and Islamabad (30) has the lowest number Multan 50 45 of public health facilities. It is important to have Rawalpindi 60 32 Islamabad 26 30 at least one public health facility in each UC, Quetta 50 63 which is not the case for 07 cities except Lahore Peshawar 97 110 where only 02 UCs remain without any public Total 626 578 health facility.

4.3 EPI Facilities 4.3.1 UCs with/without EPI Facilities Table 43: UCs with/without EPI Facilities UCs with EPI UCs without EPI Cities Overall, 26% UCs do not have any EPI facilities. Facilities Facilities Within 05 cities of Punjab, the trend is mainly Faisalabad 62 55% 51 45% driven by Gujranwala with 72% UCs not having Gujranwala 18 28% 46 72% Lahore 165 99% 1 1% EPI facilities. On the other hand, Lahore is the Multan 34 68% 16 32% only city in which all UCs have EPI facilities Rawalpindi 29 48% 31 52% available within them. About half of the UCs of Islamabad 18 69% 8 31% Quetta 41 82% 9 18% Rawalpindi (52%) is devoid of EPI facilities. Peshawar 94 97% 3 3% Total 461 74% 165 26% 4.3.2 EPI Facilities Vs. Union Councils

There are a total of 592 EPI facilities located in Table 44: EPI Facilities Vs. UCs 461 UCs. Within 05 cities of Punjab, more than Total UCs # of EPI Facilities in Total Cities half of the (220) EPI facilities are located in UCs Faisalabad 113 67 Lahore whereas the lowest number of such Gujranwala 64 18 facilities is found in Gujranwala (18). 165 UCs Lahore 166 220 Multan 50 45 across eight cities are devoid of any EPI Rawalpindi 60 29 facilities. Highest number of UCs without EPI Islamabad 26 24 facilities is found in Gujranwala (72%), Quetta 50 69 Peshawar 97 120 Rawalpindi (52%) and Faisalabad (45%). A Total 626 592 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 Table 45: Outreach Vaccination Services Cities Availability of Outreach Vaccination Services services available within them. Five cities of Faisalabad 113 100% Punjab and Peshawar and Quetta have 100% Gujranwala 64 100% Lahore 166 100% outreach vaccination services available at the Multan 50 100% UC level. Only 62% UCs of Islamabad have Rawalpindi 60 100% outreach services available to them. It is Islamabad 16 62% Quetta 50 100% important to know that 29% slums/underserved Peshawar 97 100% areas are devoid of any outreach vaccination Total 616 98% 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 Table 46: Status of Functional ILR EPI facilities with EPI facilities with Non Lined Refrigerators available within them. All Cities Functional ILR Functional ILR EPI facilities located in five cities of Punjab, Faisalabad 67 100% 0 0% Quetta and Peshawar have functional Ice Lined Gujranwala 18 100% 0 0% Refrigerators available within them. In some Lahore 220 100% 0 0% Multan 45 100% 0 0% instances, it is possible that the proper Rawalpindi 27 93% 2 7% functionality of ILRs is disrupted by frequent Islamabad 24 100% 0 0% power breakdowns. Quetta 111 93% 9 8% Peshawar 67 97% 2 3% Total 579 98% 13 2%

4.4 Nutrition Services 4.4.1 Presence of Nutrition Services Overall, 50% UCs have nutrition services in 4 Table 47: Nutrition Services UCs with Nutrition UCs without Nutrition cities namely Multan (68%), Peshawar (66%), Cities Services Services Faisalabad (56%) and Islamabad (50%). Faisalabad 63 56% 50 44% Nutrition services are not available in 37% UCs. Gujranwala 19 30% 45 70% This is primarily driven by Quetta (82%) and Lahore 166 100% 0 0% Multan 34 68% 16 32% Gujranwala (70%) being devoid of such Rawalpindi 28 47% 32 53% services. On the other extreme, all UCs of Islamabad 13 50% 13 50% Quetta 9 18% 41 82% Lahore (100%) have nutrition services available Peshawar 64 66% 33 34% within them. Total 396 63% 230 37%

4.4.2 Types of Nutrition Services Table 48: Types of Nutrition Services School Sessions Cities Fixed Sites Overall, there are four types of nutrition services Session by LHWs being offered: Faisalabad 56% 0% 0% Gujranwala 30% 0% 16%  Fixed Sites Lahore 7% 13% 87%  Temporary Sites Multan 68% 0% 0% Rawalpindi 47% 0% 47%  School Sessions Islamabad 19% 0% 31%  Sessions by LHWs Quetta 2% 18% 18% Peshawar 0% 2% 66% Total 26% 5% 42% 4.4.2a Fixed Sites Only Quetta have (18%) temporary nutrition 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 Table 49: Number of Vaccinators Total EPI # of Vaccinators in housed. Health facilities operating at a secondary Cities Facilities Total UCs or tertiary level have a higher number of Faisalabad 67 75 vaccinators as these are expected to cater to a Gujranwala 18 19 Lahore 220 356 larger number of patients and caregivers. A total Multan 45 45 of 931 vaccinators are working within 592 EPI Rawalpindi 29 29 Islamabad 24 41 facilities. On average, there are 1.6 vaccinator Quetta 69 120 available per EPI facility. Within Punjab, Lahore Peshawar 120 246 takes the lead with a total of 356 vaccinators Total 592 931 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.

4.5.2 Lady Health Workers Table 50: UCs Uncovered by LHWs Total # of Overall, 25% UCs remains uncovered by LHWs. Cities Total UCs Uncovered by LHW LHWs There are total 3793 Lady Health Workers Faisalabad 173 44 39% deployed in 75% UCs. Highest percentage of Gujranwala 64 9 14% Lahore 1335 3 2% UCs uncovered by LHWs is in Rawalpindi (52%) Multan 265 8 16% and Islamabad (46%). A negligible percentage of Rawalpindi 135 31 52% UCs in Lahore (2%) and Multan (16%) are Islamabad 145 12 46% Quetta 516 19 38% uncovered by LHWs. Peshawar 1160 33 34% Total 3793 159 25% 4.5.3 Dengue Workers

Overall, dengue workers are available in 92% Table 51: Dengue Workers UCs of 6 cities. 100% UCs of 05 cities of Punjab Cities UCs with Dengue Workers and Peshawar have dengue workers. Since Faisalabad 113 100% Gujranwala 64 100% dengue is not an issue for Quetta therefore, Lahore 166 100% department of health have not deployed any Multan 50 100% Rawalpindi 60 100% dengue workers. Similarly in Islamabad, Islamabad NA NA temporary staff is deployed during dengue seaso Quetta 0% 0% Peshawar 97 100% Total 550 92%

Chapter 5 Status of EPI Facilities

59% 14%

EPI Facilities are EPI Facilities Work for Without SoP Less than 6 Hours

36% 26% 35% EPI Facilities have EPI Facilities are EPI Facilities are Inadequate Seating Without Toilets Without Drinking Capacity Water Facility

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 Figure 4: Ownership Status of Buildings of EPI Facilities 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 Rented/Housed in Private/Welfare Owned or housed in private or welfare health 15% facilities. 100% EPI facilities in Faisalabad Total 85% 0% and Rawalpindi are owned by the FSD 100% 0% government. Majority of the EPI facilities of RWP 100% 6% Quetta (93%), Lahore (94%), Islamabad LHR 94% 7% (79%) and Peshawar (78%) are also owned QTA 93% 21% by government, while the about half of the IBD 79% 22% PWR 78% facilities in Gujranwala (50%) and Multan 43% MTN 57% (57%) are housed in rented/ or private 50% GJR 50% buildings.

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 Figure 10: Gender Mixed Waiting Areas Two cities namely Peshawar and Quetta have relatively higher preferences for gender-segregated services. Overall, 59% 78% EPI facilities do not have gender 73% 65% segregated waiting areas. Highest 59% percentage of EPI facilities in Gujranwala 52% 52% 54% (78%), Lahore (73%) and Faisalabad (65%) 40% 42% 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 MTN RWP QTA PWR IBD FSD LHR GJR Total (40%) have relatively better situation where less than half of the waiting areas are not gender segregated.

5.1.2b Inadequate Seating Capacity Figure 11: Inadequate Seating Capacity Overall 36% EPI facilities have inadequate seating capacity in their waiting areas. Over 30% EPI facilities of seven out of 44% 38% eight cities report about inadequate seating 37% 37% 37% 36% 32% capacity. Highest percentage of EPI 30% facilities with inadequate seating capacity is found in Gujranwala (44%). Lowest percentage of inadequate seating capacity 17% is found in EPI facilities of Islamabad (17%). In order to attract caregivers towards EPI facilities, it is extremely important to ensure caregiver friendly IBD MTN RWP LHR QTA PWR FSD GJR Total gender segregated adequate seating capacity.

5.1.3 Drinking Water Figure 12: Unavailability of Drinking Water Overall 35% EPI facilities do not have drinking water facility. Highest 72% percentages of EPI facilities that report about unavailability of drinking water are 48% 42% 43% found in three cities of Punjab (Gujranwala 35% - 72%, Multan - 43%, Lahore - 42%) and 25% 21% 16% Quetta (48%). A small percentage of 12% Islamabad (21%) and Peshawar (25%) also report about unavailability of drinking water in their respective EPI facilities. FSD RWP IBD PWR LHR MTN QTA GJR Total

5.1.4 Toilets Figure 5: Unavailability of Toilets 5.1.4a Unavailability of Toilets Availability of useable toilets is extremely important for the patients and their 42% attendants. Overall 26% of the total 39% 35% assessed EPI facilities report about 33% unavailability of toilets. Highest 26% 26% percentages of EPI facilities that report 21% about unavailability of toilets are in Rawalpindi (42%). The situation of Peshawar (21%) and Quetta (26%) is 8% comparatively better. The trend varies 0% across cities of Punjab as 100% EPI facilities of Faisalabad have toilet FSD IBD PWR QTA MTN LHR GJR RWP Total 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 Figure 14: Gender Mixed Toilets From those EPI facilities where toilets are available, it is interesting to put a 68% gender lens on them. Majority of the Gender Mixed Toilets women in Pakistan feel more comfortable in using gender-segregated 44% toilets. Because of the limited number of 41% toilets in EPI facilities, majority of the 31% 25% 21% toilets are gender mixed. Overall 31% 17% 19% of the total EPI facilities do not have 11% gender-segregated toilets. Highest percentage of EPI facilities without gender-segregated toilets is found in RWP MTN QTA IBD LHR PWR GJR FSD Total 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 Figure 15: Unusable Toilets In EPI facilities where toilets are available 14% are not usable. Highest percentage of unusable toilets is found 27% in Peshawar (27%), Multan (20%) and Gujranwala (17%). None of toilets of 20% EPI facilities of Rawalpindi (0%) are 17% unusable. Less than 15% toilets are 13% 14% unusable in EPI facilities of four cities namely Quetta (13%), Islamabad (9%), 8% 9% Lahore (8%) and Faisalabad (6%). The 6% low usability of toilets is because of multiple factors including unavailability 0% of water, filthiness or physical damage RWP FSD LHR IBD QTA GJR MTN PWR Total of toilet facility.

5.2 Systems Figure 16: Standard Operating Procedures 5.2.1 Standard Operating Procedures Standard Operating Procedures (SoP) guide 89% facility staff about the quality standards and 81% 83% help them avoid malpractices thus availability 63% 67% of SoP is a basic step towards its 55% 59% compliance. Overall SoPs are not available in 51% 59% of the total assessed EPI facilities. Gujranwala (89%), Islamabad (83%) and 21% Quetta (81%) have the highest percentage of EPI facilities without SoPs. The lowest percentage of EPI facilities in Faisalabad FSD LHR PWR RWP MTN QTA IBD GJR Total (21%), report unavailability of SoPs.

Figure 17: Working for Less than Six Hours 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 69% 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 25% less than 6 hours per day. Highest 14% 9% percentage of EPI facilities in Quetta (69%) 5% 6% work for less than 6 hours. About a quarter 0% 0% 2% of EPI facilities of Islamabad also report MTN FSD LHR RWP GJR PWR IBD QTA Total 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 Figure 6: Non Functional ILR found non functional in total assessed EPI facilities. City wise comparison reflects a small percentage of EPI facilities in Total 3% Rawalpindi (11%) and Peshawar (08%) and RWP 11% Quetta (04%) with non-functional ILR. EPI PWR facilities of five cities have functional ILR. 8% There are multiple reasons of non- QTA 4% functional ILR such as technical damage or IBD 0% power break down. It is important to ensure proper cold chain in all available EPI LHR 0% facilities to continue uninterrupted quality FSD 0% provision of vaccine service delivery. MTN 0%

5.3.2 Availability of Supplies GJR 0% 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.

5.3.2a Ice Packs Figure 19: Availability of Supplies Overall 3% EPI facilities report about shortage of ice packs from five cities. These Auto Disable Syringes Safety Boxes are Rawalpindi (11%), Quetta (7%), Multan Vaccine Carrier Ice Packs (10%), Peshawar (2%) and Lahore (2%). Total 96% 99% 98% 97% 5.3.2b Vaccine Carrier LHR 100% 100% 98% 98% Overall 2% EPI facilities report about FSD 100% 100% 100% 100% shortage of vaccine carrier from four cities. MTN 100% 100% 100% 90% These are Rawalpindi (11%), Peshawar QTA 100% 100% 98% 93% (1%), Quetta (2%) and Lahore (2%). IBD 96% 100% 100% 100% GJR 94% 100% 100% 100% 5.3.3c Safety Boxes PWR 91% 97% 99% 98% Overall 1% EPI facilities report about RWP 79% 100% 89% 89% 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%).

Figure 20: Shortage of Vaccine 5.3.2b Vaccines In order to ensure, uninterrupted vaccination service provision, it is important to ensure Sometimes Shortage Mostly Shortage sufficient stock of vaccine at all times. 83% 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 29% facilities report frequent shortage of vaccines from Quetta (6%) and Peshawar (2%) only 14% 12% 3% 6% and infrequent shortage of vaccine from four 0%0% 0%0% 0%0% 0%0% 0% 2% 0% 1% cities namely Gujranwala (83%), Quetta RWP MTN LHR IBD FSD PWR QTA GJR Total (29%) and Peshawar (14%).

Figure 21: Waste Management Practices 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 Waste Management burning and burial of the waste as a waste 2% Total 98% 0% management practice. A small percentage PWR 100% 0% of EPI facilities in Multan (20%) and Lahore QTA 100% 0% (2%) report about the waste pick up system IBD 100% WMC Vehicle 0% by Waste Management Company (WMC) FSD 100% Burn & Buried 0% vehicle. RWP 100% 0% GJR 100% 2% LHR 98% MTN 20% 80%

5.5 Human Resource Figure 22: Availability of Vaccinators 5.5.1 Vaccinators Overall 99% EPI facilties report availability of one or more vaccinators in seven out of 100% 100% 100% 100% 100% 100% 100% eight cities. The number of vaccinator for 99% 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 88% 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 IBD QTA GJR RWP MTN FSD LHR PWR Total than one vaccinator hence large number of children can be catered on a daily basis.;

5.5.2 Lady Health Visitors Figure 23: Availability of 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 79% 74% 76% tertiary hospitals and Basic Health Unit 64% 61% may have deployment of LHVs but an 57% 59% 60% independent EPI Facility may not have deployment of LHVs under the administrative system. Primary purpose of 22% 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 GJR LHR QTA MTN PWR RWP FSD IBD Total 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%).

Chapter 6 Situation in Super High Risk Union Councils

88% 56% Super High Risk UCs Slum/ Underserved are With Slums/ Areas are Not Underserved Areas Covered by LHWs

92% 41% Slums/ Underserved Children in 21% Areas Reported Non Slums/Underserved Children in Presence of EPI are Partially Slums/Underserved Facility Vaccinated Areas Are Zero Dose

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 Table 52: Health Facilities in SHRUCs Cities Number of SHRUCs Number of Health Facilities 32 SHRUCs have 45 health facilities. When Peshawar 18 22 number of health facilities is compared with the Quetta 6 9 Karachi 8 14 number of SHRUCs, it shows highest number of Total 32 45 health facilities in Karachi where 8 SHRUCs

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

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% Table 53: SHRUCs with/without Health Facilities Cities SHRUCs with SHRUCs without Total SHRUCs are without any health facility. About a Health Facilities Health Facilities SHRUCs quarter of the SHRUCs of Karachi (33%) and Peshawar 15 3 18 Quetta 6 0 6 Peshawar (20%) are found without Public health Karachi 6 2 8 facilities. None of the SHRUCs of Quetta are Total 27 5 32 found without health facility. % 84% 16% 100%

6.1.3 EPI Facilities 32 SHRUCs have 55 EPI facilities. When Table 54: Number of EPI Facilities in SHRUCs number of EPI facilities is compared with the Cities Number of SHRUCs Number of EPI Facilities number of SHRUCs, it shows highest number of Peshawar 18 24 EPI facilities in Karachi where 8 SHRUCs have Quetta 6 9 Karachi 8 22 22 EPI facilities. Peshawar has lowest number Total 32 55 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 Table 55: SHRUCs with/without EPI Facilities of SHRUCs are without any EPI facility. It would Cities SHRUCs with SHRUCs without Total be interesting to analyse the following two factors EPI Facilities EPI Facilities SHRUCs Peshawar 18 0 18 to assess the appropriateness of the number of Quetta 6 0 6 EPI facility per UC: (a) Population of each UC; Karachi 8 0 8 Total 32 0 32 (b) distance of residential areas to and from EPI % 100% 0% 100% facility location and duration.

6.1.5 Number of Vaccinators Overall 79 vaccinators are working in 55 EPI Table 56: Number of Vaccinators Vs. Number of EPI facilities located in 32 SHRUCs. Highest number Facilities of vaccinators is found in EPI facilities of Cities Number of EPI Number of Vaccinators Facilities Peshawar (47) while lowest number of Peshawar 24 47 vaccinators is found in EPI facilities of Karachi Quetta 9 18 Karachi 22 14 (14). Total 55 79

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 Table 57: SHRUCs with/without Outreach Vaccination Cities SHRUCs with SHRUCs without Total SHRUCs imply either service delivery has some Outreach Outreach SHRUCs gaps or caregivers are unaware of importance Peshawar 10 0 18 of vaccination and component on demand Quetta 6 0 6 Karachi 8 0 8 generation is weak. Total 32 0 32 % 100% 0% 100% 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 Table 58: SHRUCs with/without LHWs Coverage deployment of LHWs. LHWs are important Cities SHRUCs with SHRUCs without Total LHWs LHWs SHRUCs health resource which may play an important Peshawar 13 5 18 role in demand generation and reduce number Quetta 4 2 6 of refusals through their house to house Karachi 8 0 8 Total 25 7 32 mobilization. % 78% 22% 100%

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 Table 59: SHRUCs with/without Slums/Underserved Cities SHRUCs SHRUCs with SHRUCs Peshawar and Quetta do not have Slums/ without Slums/ slums/underserved areas while 100% SHRUCs Underserved Underserved Peshawar 18 15 3 of Karachi are with slums/underserved areas. It Quetta 6 5 1 is important to know the number of Karachi 8 8 0 Total 32 28 4 slums/underserved areas and target population % 100% 88% 12% 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 Table 60: Slums/Underserved Areas in SHRUCs Cities Slums Underserved Total areas is found in Quetta (120) followed by Peshawar 102 0 102 Peshawar (102). The concentration of Quetta 110 10 120 Karachi 77 0 77 slums/underserved areas in relation to the Total 289 10 299 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 Table 61: Types of Residents in Slums/Underserved areas in Peshawar (29%) are temporary Cities Permanent Temporary Other displaced and another 9% residents belong to Displaced Nationality other Nationalities. Similarly slums/underserved Peshawar 62% 29% 9% Quetta 86% 7% 7% areas of Quetta have highest percentage for Total 70% 21% 9% permanent settlers (86%) and lowest Karachi This information was not collected while profiling percentages for temporary displaced (7%) and slums residents belonging to other Nationalities (7%).

6.2.4 Population of Slums/Underserved Areas Approximate population of slums/underserved Table 62: Population of Slums/Underserved Areas areas is about 1 Million. Although lowest Cities Slums Underserved Total number of slums/underserved areas are found in Peshawar 281,813 0 281,813 Quetta 177,684 43,480 221,164 8 SURUCs of Karachi but the population size is Karachi 510,993 0 510,993 highest here. The population size of Total 970,490 43,480 1,013,970 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 Table 63: Slums/Underserved Areas Uncovered by LHWs covered by LHWs with highest percentage in Cities LHW Covered LHW Uncovered Total Peshawar 52% 48% 100% Peshawar (52%). Almost 70% Quetta 30% 70% 100% slums/underserved areas in Quetta and 45% Karachi 55% 45% 100% slums/underserved areas in Karachi are not Total 44% 56% 100% covered by LHWs.

82 This information is not available for Karachi

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 Table 64: Slums/Underserved with/without Health Facilities percentage in slums/underserved areas of Cities With Health Without Health Total Facilities Facilities Peshawar (2%), Quetta (3%) and Karachi (14%) Peshawar 2% 98% 100% mention about presence of health facilities within Quetta 3% 97% 100% Karachi 14% 86% 100% 2 kilometers radius. Total 6% 94% 100%

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 Table 65: Slums/Underserved with/without EPI Facilities Cities With EPI Without EPI Total beyond 2 kilometers to access EPI facilities. A Facilities Facilities small percentage of slums/underserved areas in Peshawar 5% 95% 100% Peshawar (5%), Quetta (7%) and Karachi (13%) Quetta 7% 93% 100% Karachi 13% 87% 100% report about presence of EPI facilities within 2 Total 8% 92% 100% 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 Table 66: Slums/Underserved with/without Outreach areas in Quetta (27%) and Karachi (31%) report Cities With Outreach Without Outreach Total that they are not covered for outreach Peshawar 100% 0% 100% Quetta 73%% 27% 100% vaccination. Karachi 69% 31% 100% Total 81% 19% 100% 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 Table 67: Retention of Vaccination Card Cities Girls Boys Total higher percentage of card retention in boys (54%) Peshawar 44% 56% 29% compared to girls (46%). Highest card retention Quetta 50% 50% 26% Karachi 46% 54% 41% is found in slums/underserved areas of Karachi Total 46% 54% 30% (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 Table 68: Fully Immunized (Records+ Recall) based on records and recall basis. Higher Cities Girls Boys Total percentage of boys (54%) is found fully Peshawar 46% 54% 47% Quetta 49% 51% 21% immunized compared to girls (46%). Highest Karachi 43% 57% 45% percentage of fully immunized children is found Total 46% 54% 38% in slums/underserved areas of Karachi (45%). Lowest percentage of fully immunized children is found in Quetta (21%).

6.3.3 Partially Vaccinated Overall 41% children are found partially Table 69: Partially Vaccinated (Records+ Recall) vaccinated. Gender difference was not Cities Girls Boys Total significant for partially vaccinated children in Peshawar 50% 50% 32% Peshawar and Quetta. In slums/underserved Quetta 49% 51% 52% Karachi 54% 46% 44% areas of Karachi, a higher percentage of girls Total 50% 50% 41% (54%) are found partially vaccinated compared to boys (46%).

6.3.4 Zero Dose Overall 21% children are found having no Table 70: Zero Dose Cities Girls Boys Total antigens administered. Highest percentage of Peshawar 51% 49% 21% zero dose are found in slums/underserved areas Quetta 46% 54% 27% Karachi 50% 50% 11% of Quetta (27%) and lowest percentage of zero Total 49% 50% 21% 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.

Figure 24: Reasons of Zero Dose

Quetta Peshawar Karachi

No Permission 36% No Permission 54% No Permission 71% Unaffordability of Transport Cost 17% Fear of Side Effects 29% Fear of Side Effects 46%

No time for Vaccination 16% No time for Vaccination 10% No time for Vaccination 21% Unaware of Vacination Unaware of Vaccination 12% Timings 5% Fear of Injection 21% Unaware of Vacination 11% Fear of Injection 1% Unaffordability of Timings Transport Cost 4% Fear of Side Effects 10% Unaware of Vaccination 1% Unaware of Vacination Timings 0% Unaffordability of Fear of Injection 3% Transport Cost 0% Unaware of Vaccination 0%

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.

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.

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.

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

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.

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

BS02 Name of facilitator of group interview What is the name of your province? Select from below by typing the correct number: 1. Punjab 2. KP BS04 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 Is this a BS09 1. Slum 2. Underserved area PART B Please share current publicly known name of slum or underserved area (this should be name of the SP01 slum/underserved area that is also used in their postal address) 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. SP02 1. Registered 2. Unregistered Do you have documentary evidence? Type 1 for "yes" or 2 for "no". Skip if answer to question S02 is no. SP03 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 Do you have families other than permanent residents living here? If answer to this question is no then skip questions MT02b MT01 1. Yes 2. No What is the number of permanent resident families settled here? Please enter number of FAMILIES only, and not MT02a individuals What is the number of temporary displaced families settled here? Please enter number of FAMILIES only, and not MT02b individuals. If none, type 0. Skip this question if answer to the question MT01 is no What is the number of nomad families settled here? Please enter number of FAMILIES only, and not individuals. If MT02c none, type 0. Skip if answer to questions SP08a is no What is the number of families from conflict affected areas that are settled here? Please enter number of FAMILIES MT02d only, and not individuals. If none, type 0. Skip if answer to questions SP08a is no What is the number of non-Pakistani families settled here? Please enter number of FAMILIES only, and not MT02e individuals. If none, type 0. Skip if answer to questions SP08a is no Any there families settled other than explained in answers to the earlier questions? Please enter number of MT02f FAMILIES only, and not individuals. If none, type 0. Skip if answer to questions SP08a is no PART D 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 HF01 1. Yes 2. No If there are any functional health facilities having MBBS qualified doctor then how many of these are public health HF02a facilities? Reply with a number. If there are none, type X. Skip this question if the answer to the question HF01 is no 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 HF04 2) 1 - 2 Km 3) 2 - 3 Km 4) 3 - 4 Km 5) 4 - 5 Km 6) 5 + Km Does this public health facility offer the service of vaccination of children? Skip this question if the answer to the question HF01 is no HF05a 1. Yes 2. No

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 HF05b 1. Yes 2. No 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 HF05c 1. Yes 2. No 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 HF05d 1. Yes 2. No Does this public health facility offer any other facilities? Skip this question if the answer to the question HF01 is no HF05e If yes, please describe. If none other, type X Does this public health facility have functional ambulance? HF 06 1. Yes 2. No How many Private profit making health facilities having MBBS doctor are located in this slum or underserved area? HF02b Reply with a number. If there are no private health facility in this slum or underserved area then type X 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 HF07. 3) 2 - <3 Km 4) 3 - <4 Km 5) 4 - <5 Km 6) 5 + Km Does this private for-profit health facility have functional ambulance? Skip this question if the answer to the question HF01 is no HF 08. 1. Yes 2. No Does this private for-profit facility offer vaccination of children? Skip this question if the answer to the question HF01 is no HF09a. 1. Yes 2. No 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 HF09b. 1. Yes 2. No 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 HF09c. 1. Yes 2. No Does this private for-profit facility offer obstructive care and delivery services? Skip this question if the answer to the question HF01 is no HF09d. 1. Yes 2. No Does this private for-profit facility offer any other services? If yes, please describe what those services are in HF09e. 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 How many health facilities having MBBS qualified doctor located in your slum or underserved area are run by any HF02c. 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 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. HF02d. 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 Are you aware of transport services offered by the government for any health related emergencies? HF10. 1. Yes 2. No Are you aware of 1122 by the government to respond to any domestic accidental emergency? HF11a. 1. Yes 2. No Are you aware of 1038 by the government to respond to emergency related to the situation of pregnant women? HF11b. 1. Yes 2. No 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 HF12. 1. Yes 2. No PART E Are there any vaccination services offered for children and women in this slum or underserved area?If the answer to EP01. this question is no then skip questions from EP02a to EP02f 1. Yes

2. No

Are there any fixed EPI facilities for vaccination in this slum or underserved area? Skip this question if answer to question EP01 is no EP02a 1. Yes 2. No Who is running this fixed EPI facility? Skip this question if answer to question EP01 is no 1. Government 2. Private EP03. 3. Welfare organisation 4. Cantonment 5. Other 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 EP04. 3. 2 - 3 Km 4. 3 - 4 Km 5. 4 - 5 Km 6. 5 + Km Are there outreach vaccination camps in this slum or underserved area? Skip this question if answer to question EP01 is no EP02b. 1. Yes 2. No Do Lady Health Workers do the vaccination? Skip this question if answer to question EP01 is no EP02c. 1. Yes 2. No Are there overnight stay of mobile vaccinators for vaccination camps Skip this question if answer to question EP01 is no EP02d. 1. Yes 2. No Do doctors in private health facility do the vaccination? Skip this question if answer to question EP01 is no EP02e. 1. Yes 2. No Are there any system for vaccination in this slum or underserved area which is not explained in the answers to EP02f. 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 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 WA01 2. Well 3. Hand pump 4. Tube wells 5. Other If acquire domestic water through any water supply system is available in this slum what is the duration of water WA02 availability? Please enter number of hours, e.g., type "4" if the water comes for 4 hours. If no running water available, type X 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 TO01. 1. Yes 2. No Approximately how many houses of this slum or underserved area have toilets? Enter number only. If the answer to To02a. the question TO01 is no then skip this question How many total houses of this slum or underserved area do NOT have toilets? Enter number only. if answer of To02b. TO02a is less than the total number of houses in this slum or underserved area then this question will filled otherwise skip it How many total houses are located in this slum or underserved area? Enter number only. (This question is asked to To02c. 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 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 TO 03a 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 If toilets exist in any of the houses of this slum or underserved area, please specify how many traditional pits toilets TO 03b 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 If toilets exist in any of the houses of this slum or underserved area, please specify how many open pits are there in TO 03c the slum/underserved area which people use as toilets? Please enter NUMBER of such type of toilets only. If there are none, type 0. Skip if answer to question TO01 is no TO 03d Please specify if there are ANY OTHER types of toilets in the slum/underserved area, which we have not asked you

about yet. If so, please describe what type and how many are there. If there is no other type, type X. Skip if answer to question TO01 is no If toilet exists in all or some of the houses of this slum or underserved area, please explain approximately how many TO 04. persons in majority of the houses share one toilet? Enter number only. Skip if answer to question TO01 is no 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 To05. 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 How many houses of this slum or underserved area have Kacha type of infrastructure as the main residential area of TH 01b. 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 How many houses of this slum or underserved area have Pacca type of infrastructure as the main residential area of TH 01c. 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 How many houses of this slum or underserved area have mixed type of infrastructure (partially Pacca and partially TH 01d. 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 How many houses of this slum or underserved area have tented type of infrastructure as the main residential area of TH 01e. 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 Are there houses in this slum or underserved area having infrastructure other than explained in earlier questions as TH01f 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 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 SWM 01a 1. Yes 2. No What is the condition of drains regarding disposal of waste water? 1. Drains have running water SWM 01b 2. Drains are filthy 3. Drains are choked 4. Any other 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 SWM02a. 1. Yes 2. No 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 SWM 02b. 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 Are there schools in this slum or underserved area? If the answer to this question is no then skip questions ED02a to ED03a ED 01. 1. Yes 2. No Are there schools by government? Skip this question if the answer to question ED01 is no ED02a. 1. Yes 2. No Are there for profit schools by private sector? Skip this question if the answer to question ED01 is no ED02b. 1. Yes 2. No Are there schools by welfare trust or charity? Skip this question if the answer to question ED01 is no ED02c. 1. Yes 2. No Are there any Maktab schools by religious group(s)? Skip this question if the answer to question ED01 is no ED02d. 1. Yes 2. No Are there any other type of schools which are not explained while answering earlier questions? If yes, please ED02e. 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 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 Ed03a. 2. Between 1-2 km 3. Between 2-3 km 4. Between 3-4 km 5. More than 4 km PART K

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. CSO01. 1. Yes 2. No If registered not for profit organisations are working in this slum or underserved area, please mention its number? CSO02 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 If registered not for profit organisations are working in this slum or underserved area, please share their full names in CSO03 correct spellings. Skip this question if the answer to question CSO01 is no 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 CSO04 1. Yes 2. No 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 CSO05 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 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 CSO06a 1. Yes 2. No Does the government provide a loan scheme? Skip this question if the answer to the question CSO06a is no CSO06b 1. Yes 2. No Does the government provide a stipend scheme? CSO06c 1. Yes 2. No Does the government provide a Social Benefit Card scheme? Skip this question if the answer to the question CSO06a is no CSO06d 1. Yes 2. No Does the government provide a vocational skills scheme? Skip this question if the answer to the question CSO06a is no CSO06e 1. Yes 2. No Are there any other types of government scheme for the welfare of people of slum or underserved area, which is not CSO06f 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------

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 Number………………………….. towns of this city. 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 List of Old name of List of New Number of List of Old Number of Council Union Council Union Council 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 Population of Slum or Population of Union Council (Excluding Total Population of Union Council underserved area Population of Slum or underserved are 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 Name of slum or List of Public Health List of Private Total Council underserved area Facilities Health Facilities

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 List Public of List of Private List of Welfare List of Any No EPI Facility Union Fixed EPI Fixed EPI Fixed EPI Other Type of Councils Facilities Facilities Facilities Fixed EPI Facilities

VA 02. State the number and functionality of ILR or Refrigerator in Fixed EPI Facility (vaccination centres)? # Names of Union Public Fixed EPI Private Fixed Welfare Fixed Any Other Type of Fixed EPI Council Facilities EPI Facilities EPI Facilities Facilities

Functional Non Funct Non Functi Non Functional Non Functi ional Func onal Functi Functiona onal tional onal l

VA 03. What is the number and status of availability of currently active vaccinator? # New Name of Union List of vaccinator List of vaccinator in List of Vaccinator in Fixed EPI Facility Council in Public Health Private (vaccination centre) established by other Facility Health Facility than public sector organisation

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?

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

Annex 4: Analysis of Profiling of Slums/Underserved Areas

Table 1: Number of Slums and Underserved Cities Slums Underserved Sub Total Faisalabad 169 297 466 Gujranwala 82 165 247 Lahore 356 637 993 Multan 216 104 320 Rawalpindi 76 62 138 Punjab Total 899 1265 2164 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

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 Cities Permanent Resident Temporary Displaced Other Nationality Total Faisalabad 131,586 27,639 12 159,237 Gujranwala 170,230 16,178 0 186,408 Lahore 411,531 47,064 1,527 460,122 Multan 63,005 6,064 350 69,419 Rawalpindi 60,066 13,749 300 74,115 Punjab Total 836,418 110,694 2,189 949,301 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) Cities Permanent Resident Temporary Displaced Other Nationality Total Faisalabad 200,352 44,278 12 244,642 Gujranwala 224,384 18,333 0 242,717 Lahore 624,925 78,982 1,632 705,539 Multan 154,116 18,816 1,057 173,989 Rawalpindi 129,215 32,044 3,402 164,661 Punjab Total 1,332,992 192,453 6,103 1,531,548 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 Public Private Welfare/Trust Other Total Public Private Welfare/Trust Other Total Grand Cities 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 9 2 0 0 11 1 4 0 0 5 16 Total 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 With Public With Private With Both Public and Without any Cities Total Total Health Facilities Health Facilities Private Health Facilities Health Facilities 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

Table 7b: Underserved having Private and Public Health Facilities With Public With Private With Both Public and Without any Cities Total Total Health Facilities Health Facilities Private Health Facilities Health Facilities Faisalabad 0 0 0 0 297 297 Gujranwala 1 4 0 5 160 165 Lahore 0 0 0 0 637 637 Multan 0 0 0 0 104 104 Rawalpindi 0 0 0 0 62 62 Punjab Total 1 4 0 5 1260 1265 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 With Public With Private With Both Public and Without any Cities Total Total Health Facilities Health Facilities Private Health Facilities Health Facilities 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 Faisalabad 2 0 167 169 Gujranwala 0 0 82 82 Lahore 0 0 356 356 Multan 0 0 216 216 Rawalpindi 0 0 76 76 Punjab Total 2 0 897 899 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 Faisalabad 0 0 297 297 Gujranwala 4 0 161 165 Lahore 0 0 637 637 Multan 0 0 104 104 Rawalpindi 0 0 62 62 Punjab Total 4 0 1261 1265 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 Faisalabad 2 0 464 466 Gujranwala 4 0 243 247 Lahore 0 0 993 993 Multan 0 0 320 320 Rawalpindi 0 0 138 138 Punjab Total 6 0 2158 2164 Islamabad 9 1 53 63 Quetta 3 0 312 315 Peshawar 7 0 565 572 Grand Total 25 1 3088 3114

Table 9: EPI Facilities Slums Underserved Areas Slums/Underserved Total Cities 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 Slums without EPI Cities 0-2km 3km 4km 5+km Total facility Faisalabad 16 0 0 0 153 169 Gujranwala 1 0 0 0 81 82 Lahore 15 0 0 0 341 356 Multan 8 0 0 1 207 216 Rawalpindi 5 0 0 0 71 76 Punjab Total 45 0 0 1 853 899 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 Rawalpindi 2 0 0 0 60 62 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

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 Punjab Total 828 1265 Islamabad 8 14 Quetta 12 34 Peshawar 22 22 Grand Total 870 1335

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 Punjab Total 1527 2164 Islamabad 43 63 Quetta 113 315 Peshawar 551 572 Grand Total 2223 3114

Table 12a: Lady Health Worker in Slums Cities LHWs Covered LHWs Uncovered Total Slums Faisalabad 31 138 169 Gujranwala 5 77 82 Lahore 222 134 356 Multan 70 146 216 Rawalpindi 33 43 76 Punjab Total 361 538 899 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 Faisalabad 72 225 297 Gujranwala 32 133 165 Lahore 324 313 637 Multan 39 65 104 Rawalpindi 18 44 62 Punjab Total 485 780 1265 Islamabad 5 9 14 Quetta 11 23 34 Peshawar 7 15 22 Grand Total 508 827 1335

Table 12c: Lady Health Worker in Slums/Underserved (Total) Cities LHWs Covered LHWs Uncovered Total Slums/Underserved Faisalabad 103 363 466 Gujranwala 37 210 247 Lahore 546 447 993 Multan 109 211 320 Rawalpindi 51 87 138 Punjab Total 846 1318 2164 Islamabad 22 41 63 Quetta 105 210 315 Peshawar 335 237 572 Grand Total 1308 1806 3114

Table 13a: Availability of 1122 Services Slums Underserved Areas Slums/Underserved Areas # of Slums Slums # of Underserve Slums/Un Slums/Under Cities Underserved Slums With Without Underserved d Without derserved served With 1122 1122 1122 1122 With 1122 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 Slums Underserved Areas Slums/Underserved Areas Slums Slums # of Cities # of Underserved With Underserved Slums/Underserv Slums/Underserv With Without Underserved Slums 1122 Without 1122 ed With 1122 ed Without 1122 1122 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 899 16 883 1265 49 1216 65 2099 Total 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 Slums Underserved Slums/Underserved Total Cities 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

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 Cities Kacha or Tented Pacca Kacha-Pacca (Mixed) Total Faisalabad 0 135,313 23,934 159,247 Gujranwala 0 141,745 44,663 186,408 Lahore 0 436,371 23,751 460,122 Multan 0 54,966 14,453 69,419 Rawalpindi 0 55,402 18,713 74,115 Punjab Total 0 823,797 125,514 949,311 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) Cities Kacha or Tented Pacca Kacha-Pacca (Mixed) Total Faisalabad 7,629 164,771 72,252 244,652 Gujranwala 8,315 168,395 66,007 242,717 Lahore 32,057 521,288 152,194 705,539 Multan 9,255 106,572 58,162 173,989 Rawalpindi 13,186 102,843 48,632 164,661 Punjab Total 70,442 1,063,869 397,247 1,531,558 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 Government Water Acquire From Other Sources Of Cities Ground Water (Well, Hand Pump, Tube Well) Supply Water Faisalabad 29 125 15 Gujranwala 7 55 20 Lahore 111 118 127 Multan 40 158 18 Rawalpindi 22 38 16 Punjab Total 209 494 196 Islamabad 12 31 6 Quetta 35 74 172 Peshawar 64 477 9 Grand Total 320 1076 383

Table 16b: Sources of Domestic Water in Underserved Ground Water (Well, Hand Cities Government Water Supply Acquire From Other Sources Of Water Pump, Tube Well) Faisalabad 88 45 164 Gujranwala 23 64 78 Lahore 276 261 100 Multan 28 46 30 Rawalpindi 35 12 15 Punjab Total 450 428 387 Islamabad 5 5 4 Quetta 12 4 18 Peshawar 2 20 0 Grand Total 469 457 409

Table 16c: Sources of Domestic Water in Slums/Underserved (Total) Government Cities Ground Water (Well, Hand Pump, Tube Well) Acquire From Other Sources Of Water Water Supply Faisalabad 117 170 179 Gujranwala 30 119 98 Lahore 387 379 227 Multan 68 204 48 Rawalpindi 57 50 31 Punjab Total 659 922 583 Islamabad 17 35 11 Quetta 47 78 190 Peshawar 66 497 9 Grand Total 789 1532 793

Table 17a : Duration of Water Availability (in case of Government Water Supply) in Slums 1-5 6-10 16-20 20+ Slums without Government Cities 11-15 hours Sub Total hours hours hours hours Water Supply 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 1-5 6-10 11-15 16-20 Slums without Government Sub Cities 20+ hours hours hours hours hours Water Supply 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) 1-5 6-10 11-15 16-20 Slums without Government Sub Cities 20+ hours hours hours hours hours Water Supply 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

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 Cities # of House Having Toilets # of Household Not Having Toilet Total Household Faisalabad 158,273 964 159,237 Gujranwala 185,953 455 186,408 Lahore 457,833 2,289 460,122 Multan 65,209 4,210 69,419 Rawalpindi 74,005 110 74,115 Punjab Total 941,273 8,028 949,301 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 Cities # of House Having Toilets # of Household Not Having Toilet Total Household Faisalabad 241,826 2,816 244,642 Gujranwala 241,502 1,215 242,717 Lahore 698,714 6,825 705,539 Multan 169,025 4,964 173,989 Rawalpindi 164,051 610 164,661 Punjab Total 1,515,118 16,430 1,531,548 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 Cities Connected with Street Drain Traditional/Open pit Sub-Total Faisalabad 101,536 56,737 158,273 Gujranwala 129,287 56,666 185,953 Lahore 191,119 266,714 457,833 Multan 25,898 39,311 65,209 Rawalpindi 26,847 47,158 74,005 Punjab Total 474,687 466,586 941,273 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

Table 19c : Type of Household Toilet in Slums/Underserved (Total) Cities Connected with Street Drain Traditional/Open pit Sub-Total Faisalabad 147,412 94,414 241,826 Gujranwala 164,772 76,730 241,502 Lahore 343,480 355,234 698,714 Multan 79,868 89,157 169,025 Rawalpindi 66,958 97,093 164,051 Punjab Total 802,490 712,628 1,515,118 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 Cities Average # of People Using Toilet 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) Cities Average # of People Using Toilet 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 Gujranwala 0 1 8 73 82 Lahore 0 0 43 313 356 Multan 1 2 6 207 216 Rawalpindi 0 1 7 68 76 Punjab Total 1 4 85 809 899 Islamabad 2 0 13 34 49 Quetta 1 2 26 252 281 Peshawar 0 0 66 484 550 Grand Total 4 6 190 1579 1779

Table 21b: Modes of Defecation Without Toilet in Underserved Cities Neighbor’s Toilets Public Toilet Open Defecation Not Applicable Sub-Total Faisalabad 0 0 18 279 297 Gujranwala 0 0 4 161 165 Lahore 0 0 18 619 637 Multan 0 0 2 102 104 Rawalpindi 0 1 2 59 62 Punjab Total 0 1 44 1220 1265 Islamabad 0 0 0 14 14 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) Cities Neighbor’s Toilets Public Toilet Open Defecation Not Applicable Sub-Total Faisalabad 0 0 39 427 466 Gujranwala 0 1 12 234 247 Lahore 0 0 61 932 993 Multan 1 2 8 309 320 Rawalpindi 0 2 9 127 138 Punjab Total 1 5 129 2029 2164 Islamabad 2 0 13 48 63 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 Faisalabad 32 92 45 169 Gujranwala 14 38 30 82 Lahore 94 142 120 356 Multan 55 122 39 216 Rawalpindi 45 20 11 76 Punjab Total 240 414 245 899 Islamabad 14 16 19 49 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 Faisalabad 79 170 48 297 Gujranwala 25 91 49 165 Lahore 65 239 333 637 Multan 22 45 37 104 Rawalpindi 23 31 8 62 Punjab Total 214 576 475 1265 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 Faisalabad 111 262 93 466 Gujranwala 39 129 79 247 Lahore 159 381 453 993 Multan 77 167 76 320 Rawalpindi 68 51 19 138 Punjab Total 454 990 720 2164 Islamabad 16 25 22 63 Quetta 49 149 117 315 Peshawar 185 363 24 572 Grand Total 704 1527 883 3114

Table 23a: Solid Waste Disposal Practices in Slums Cities Govt/WMC vehicle Other Systems Dumping on Empty Plot and Street Total Faisalabad 48 6 115 169 Gujranwala 11 4 67 82 Lahore 169 4 183 356 Multan 80 3 133 216 Rawalpindi 26 0 50 76 Punjab Total 334 17 548 899 Islamabad 13 1 35 49 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 Cities Govt/WMC vehicle Other Systems Dumping on Empty Plot and Street Total Faisalabad 129 14 154 297 Gujranwala 33 14 118 165 Lahore 458 12 167 637 Multan 55 1 48 104 Rawalpindi 41 2 19 62 Punjab Total 716 43 506 1265 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) Cities Govt/WMC vehicle Other Systems Dumping on Empty Plot and Street Total Faisalabad 177 20 269 466 Gujranwala 44 18 185 247 Lahore 627 16 350 993 Multan 135 4 181 320 Rawalpindi 67 2 69 138 Punjab Total 1050 60 1054 2164 Islamabad 16 2 45 63 Quetta 23 6 286 315 Peshawar 171 60 341 572 Grand Total 1260 128 1726 3114

Table 24a: Schools in Slums and Underserved Slums Underserved Areas Cities Total Available Not Available Total Slums Available Not Available 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 Faisalabad 327 139 466 Gujranwala 155 92 247 Lahore 794 199 993 Multan 258 62 320 Rawalpindi 96 42 138 Punjab Total 1630 534 2164 Islamabad 43 20 63 Quetta 168 147 315 Peshawar 481 91 572 Grand Total 2322 792 3114

Table 25a: Types of Schools in Slums Cities Government Private Welfare/Trust Maktab/Madrsa Other No Schools Faisalabad 55 84 9 51 2 63 Gujranwala 32 27 0 6 0 25 Lahore 187 204 19 89 0 80 Multan 140 122 4 48 1 44 Rawalpindi 27 31 10 19 0 31 Punjab Total 441 468 42 213 3 243 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 Cities Government Private Welfare/Trust Maktab/Madrsa Other No Schools Faisalabad 112 194 27 111 1 76 Gujranwala 53 52 2 12 0 67 Lahore 293 426 41 230 1 119 Multan 61 69 6 33 0 18 Rawalpindi 32 41 6 19 0 11 Punjab Total 551 782 82 405 2 291 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) Cities Government Private Welfare/Trust Maktab/Madrsa Other No Schools Faisalabad 167 278 36 162 3 139 Gujranwala 85 79 2 18 0 92 Lahore 480 630 60 319 1 199 Multan 201 191 10 81 1 62 Rawalpindi 59 72 16 38 0 42 Punjab Total 992 1250 124 618 5 534 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 0-2km 3km 4km 5+km Slums Without schools Sub Total Cities # # # # # # Faisalabad 103 3 0 0 63 169 Gujranwala 57 0 0 0 25 82 Lahore 276 0 0 0 80 356 Multan 171 0 1 0 44 216 Rawalpindi 44 0 0 1 31 76 Punjab Total 651 3 1 1 243 899 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 Rawalpindi 51 0 0 0 11 62 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

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 Slums Underserved Areas Slum/Underserved Areas Cities Available Not Available Available Not Available Available Not Available Faisalabad 2 167 13 284 15 451 Gujranwala 0 82 2 163 2 245 Lahore 10 346 28 609 38 955 Multan 0 216 1 103 1 319 Rawalpindi 3 73 1 61 4 134 Punjab Total 15 884 45 1220 60 2104 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 Punjab Types of Services Faisalabad Gujranwala Lahore Multan Rawalpindi Islamabad Quetta Peshawar Total 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 167 82 346 216 73 884 35 281 546 charity organization Total 169 82 356 216 76 899 49 281 550

Table 28b: Types of Services by CSOs in Underserved Areas Rawalpi Punjab Islamab Types of Services Faisalabad Gujranwala Lahore Multan Quetta Peshawar ndi Total ad 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) Punjab Types of Services Faisalabad Gujranwala Lahore Multan Rawalpindi Islamabad Quetta Peshawar 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

Table 29: Presence of Informal Groups Slums Underserved Slum/Underserved (Total) Cities Available Not Available Available Not Available Available Not Available Faisalabad 56 113 117 180 173 293 Gujranwala 26 56 36 129 62 185 Lahore 138 218 275 362 413 580 Multan 86 130 33 71 119 201 Rawalpindi 43 33 39 23 82 56 Punjab Total 349 550 500 765 849 1315 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 Punjab Types of Informal Groups Faisalabad Gujranwala Lahore Multan Rawalpindi Islamabad Quetta Peshawar 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- 5 0 1 12 6 24 4 3 48 Based Organization Zakat Committee 12 5 28 20 6 71 2 0 4 No Informal Groups or 113 56 218 156 33 581 24 239 400 Committees Total 169 82 356 216 76 899 49 281 550

Table 30b: Types of Informal Groups in Underserved Areas Types of Informal Punjab Faisalabad Gujranwala Lahore Multan Rawalpindi Islamabad Quetta Peshawar Groups Total Health Committee 1 0 18 0 1 20 0 0 0 Jirga/Punchaiyat 1 2 3 0 0 6 0 0 4 Masjid/ChurchCommittee 76 26 87 24 34 247 0 2 4 School Committee 0 0 0 0 0 0 4 0 0 Unregistered 0 0 75 1 0 76 0 0 2 Community-Based Organization Zakat Committee 39 8 92 8 4 151 0 0 0 No Informal Groups or 180 129 362 71 23 765 10 32 12 Committees Grand Total 297 165 637 104 62 1265 14 34 22

Table 30c: Types of Informal Groups in Slums/Underserved Areas Types of Informal Faisalabad Gujranwala Lahore Multan Rawalpindi Punjab Total Islamabad Quetta Peshawar Groups Health Committee 6 5 80 12 1 104 0 0 1 Jirga/Punchaiyat 1 3 6 1 4 15 1 16 21 Masjid/Church 110 41 130 61 61 403 18 25 81 Committee School Committee 0 0 1 4 0 5 4 0 3 Unregistered 5 0 76 13 6 100 4 3 50 Community-Based Organization Zakat Committee 51 13 120 28 10 222 2 0 4 No Informal Groups 293 185 580 227 56 1346 34 271 412 or Committees Grand Total 466 247 993 320 138 2164 63 315 572

Table 31: Availability of Welfare Scheme by Government Slums Underserved Areas Slums/Underserved

Cities Total Total Total Uncover Covered Uncovered Covered Uncovered Covered Slums Underserved slums/Underserved 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 899 350 549 1265 795 470 2164 1145 1019 Total 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 Social Benefit Vocational Skills Loan Scheme Stipend Scheme Other Cities Type of work Card Scheme Yes No Yes No Yes No Yes No Yes No Slum 10 0 4 1 40 3 2 2 0 4 Faisalabad Underserved 15 0 20 2 101 2 0 2 0 2 Slum 13 2 5 2 20 2 1 1 1 1 Gujranwala Underserved 6 8 20 8 60 8 6 2 5 4 Slum 15 1 30 2 100 1 0 2 0 2 Lahore Underserved 82 7 78 11 345 15 5 15 2 20 Slum 4 2 14 2 60 1 2 2 0 4 Multan Underserved 1 2 1 2 24 2 2 1 0 3 Slum 1 1 7 1 20 2 1 1 0 2 Rawalpindi Underserved 2 0 2 0 18 0 0 0 0 0 Slum 43 6 60 8 240 9 6 8 1 13 Punjab Total Underserved 106 17 121 23 548 27 13 20 7 29 Total 149 23 181 31 788 36 19 28 8 42 Slum 0 21 1 20 20 1 0 21 0 21 Islamabad Underserved 1 3 1 3 2 0 0 4 0 4 Total 1 24 2 23 22 1 0 25 0 25 Slum 0 2 0 2 32 2 2 0 0 2 Quetta Underserved 0 0 0 0 0 0 0 0 0 0 Total 0 2 0 2 32 2 2 0 0 2 Slum 5 294 38 261 250 13 6 293 0 299 Peshawar Underserved 0 9 0 9 9 0 0 9 0 9 Total 5 303 38 270 259 13 6 302 0 308 Slum 48 323 99 291 542 25 14 322 1 335 Grand Total Underserved 107 29 122 35 559 27 13 33 7 42 Total 155 352 221 326 1101 52 27 355 8 377

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

Table 1b: Status of Slums/Underserved in Union Councils Cities UCs with Slums/Underserved UCs without Slums/Underserved Total Faisalabad 86 27 113 Gujranwala 58 6 64 Lahore 127 39 166 Multan 36 14 50 Rawalpindi 44 16 60 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

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 Faisalabad 52 61 113 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 Grand Total 430 196 626

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 Faisalabad 62 51 113 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 Grand Total 461 165 626

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 Grand Total 579 13 592

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 Faisalabad 63 50 113 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 Grand Total 396 230 626

Table 9b: Types of Nutrition Services in UCs Cities Fixed Temporary Sites School Session Sessions by LHWs No Nutrition Services Faisalabad 63 0 0 0 50 Gujranwala 19 0 0 0 45 Lahore 12 0 22 144 0 Multan 34 0 0 0 16 Rawalpindi 28 0 0 28 32 Islamabad 5 0 0 8 13 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

Table 11: Number of UCs Covered by LHWs Cities UCs Covered by LHWs UCs Uncovered by LHWs Total UCs Total Number of LHWs Faisalabad 69 44 113 173 Gujranwala 55 9 64 64 Lahore 163 3 166 1335 Multan 42 8 50 265 Rawalpindi 29 31 60 135 Islamabad 14 12 26 145 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 Faisalabad 113 0 113 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 Grand Total 550 50 600

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 Grand Total 359 63 422 Note: 2 EPI Centres are donated by Peshawar University & Family Medical Care Centre

Table 3 Types of EPI Facilities City Government Private Charity Total Faisalabad 34 0 0 34 Gujranwala 18 0 0 18 Lahore 120 7 0 127 Multan 30 0 0 30 Rawalpindi 19 0 0 19 Sub total - Punjab 221 7 0 228 Islamabad 19 5 0 24 Quetta 52 0 2 54 Peshawar 114 0 2 116 Grand Total 406 12 4 422 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 Grand Total 58 364 422

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 Sub total - Punjab 108 120 228 Islamabad 4 20 24 Quetta 10 44 54 Peshawar 52 64 116 Grand Total 174 248 422

Table 6: Availability of LHVs in EPI Facilities City Available Not Available Total Total # of LHVs Faisalabad 26 8 34 31 Gujranwala 4 14 18 5 Lahore 72 55 127 81 Multan 18 12 30 21 Rawalpindi 14 5 19 20 Sub total - Punjab 134 94 228 158 Islamabad 19 5 24 31 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 Faisalabad 34 0 34 40 Gujranwala 18 0 18 23 Lahore 127 0 127 225 Multan 30 0 30 31 Rawalpindi 19 0 19 19 Sub total - Punjab 228 0 228 338 Islamabad 21 3 24 31 Quetta 54 0 54 99 Peshawar 116 0 116 264 Grand Total 419 3 422 732

Table 8: Vaccine Supplies Availability of Types of Vaccine Supplies Cities Auto Disable Syringes Safety Boxes/ Sharp Containers Vaccine Carrier (s) Icepacks Faisalabad 34 34 34 34 Gujranwala 17 18 18 18 Lahore 127 127 124 125 Multan 30 30 30 27 Rawalpindi 15 19 17 17 Sub total - Punjab 223 228 223 221 Islamabad 23 24 24 24 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 Faisalabad 1 0 33 34 Gujranwala 15 0 3 18 Lahore 0 0 127 127 Multan 0 0 30 30 Rawalpindi 0 0 19 19 Sub total - Punjab 16 0 212 228 Islamabad 0 0 24 24 Quetta 16 3 35 54 Peshawar 17 2 97 116 Grand Total 49 5 368 422

Table 10: Availability of Ice Lined Refrigerators City Available Functional Available Non-Functional Not Available Total Faisalabad 34 0 0 34 Gujranwala 18 0 0 18 Lahore 127 0 0 127 Multan 30 0 0 30 Rawalpindi 17 2 0 19 Sub total - Punjab 226 2 0 228 Islamabad 24 0 0 24 Quetta 52 2 0 54 Peshawar 107 9 0 116 Grand Total 409 13 0 422

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 Sub total - Punjab 149 79 228 Islamabad 13 11 24 Quetta 28 26 54 Peshawar 60 56 116 Grand Total 250 172 422

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 Sub total - Punjab 145 83 228 Islamabad 20 4 24 Quetta 34 20 54 Peshawar 73 43 116 Grand Total 272 150 422 Note: 12 EPI Facilities having no waiting areas

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 Sub total - Punjab 142 86 228 Islamabad 19 5 24 Quetta 28 26 54 Peshawar 87 29 116 Grand Total 276 146 422

Table 14: Availability of Toilets Gender Segregated City Gender Mixed Available Not Available Total Available Faisalabad 11 23 0 34 Gujranwala 3 8 7 18 Lahore 50 32 45 127 Multan 15 5 10 30 Rawalpindi 9 2 8 19 Sub total - Punjab 88 70 70 228 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 Faisalabad 32 2 0 34 Gujranwala 8 3 7 18 Lahore 72 10 45 127 Multan 14 6 10 30 Rawalpindi 11 0 8 19 Sub total - Punjab 137 21 70 228 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 Sub total - Punjab 219 9 228 Islamabad 24 0 24 Quetta 54 0 54 Peshawar 116 0 116 Grand Total 413 9 422